Test Review Chapters 20, 21, 22 and 12 PDF

**Test Review Chapters 20, 21, 22 and 12** **How to study for this exam:** Make sure you are reading the textbook, completing the lab workbook for practice and Review Powerpoints/lectures **[Here are a few topics to pay close attention to:]** Abdominal quadrants and potential concerns **4 quad...

**Test Review Chapters 20, 21, 22 and 12** **How to study for this exam:** Make sure you are reading the textbook, completing the lab workbook for practice and Review Powerpoints/lectures **[Here are a few topics to pay close attention to:]** Abdominal quadrants and potential concerns **4 quadrants** **RUQ = liver, gallbladder, duodenum, head of pancreas, right kidney** - **Pain in this area could be cholecystitis, cholelithiasis, or biliary colic** **RLQ = cecum, appendix, right ovary & tube (female) , right ureter, right spermatic cord (male)** - **Pain in this area could indicate appendicitis, pelvic inflammatory disease, or ectopic pregnancy** **LUQ = stomach, spleen, left lobe of liver, body of pancreas, left kidney** - **Pain in this area could indicate PUD gastritis, ruptured spleen, or pancreatitis** **LLQ = left ovary & tube (female), left ureter, left spermatic cord (male)** - **Pain in this area could indicate diverticulitis, renal (kidney) stone, or acute bowel obstruction** **Epigastric = between coastal margins** **Umbilical = area around umbilicus** **Hypogastric or Suprapubic = area above pubic bone** Cardiac Cycles (preload etc) **The cardiac cycle is the rhythmic movement of blood through the heart. Two phases diastole and systole.** **Systole = The heart is contracting, during this blood is pumped from the ventricles and fills the pulmonary and systemic arteries. This takes up 1/3 of the cardiac cycle. AV valves are now shut.** **Diastole = The heart is relaxing, the ventricles fill up with blood. This takes 2/3 of the cardiac cycle. AV valves (tricuspid and bicuspid/mitral) are open.** **Preload = the VOLUME of blood in the ventricles at the end of diastole (end of diastolic pressure)** - **Preload is increased in hypervolemia, regurgitation or valves, and heart failure.** **Afterload = PRESSURE/resistance of the left ventricle must overcome to circulate blood.** - **Afterload is increased in hypertension, and vasoconstriction** **Cardiac Output (CO) = amount of blood pumped by the ventricles in 1 min.** - **The PRIMARY determinant of CO in normal pt. is volume status (sodium content)** **Stroke Volume (SV) = amount of blood pumped with each contraction. This is affected by the preload, afterload, and contractility** **Heart Rate (HR) = speed the heart beats in a specific amount of time.** **CO=SVxHR** **Ejection Fraction (EF) = % of the total amount of blood the left ventricle pumps out with each beat/contraction.** - **+70% = HIGH** - **46-70% = NORMAL** - **35-45% = LOW** - **-35% = RISK** Know what is included in your assessments for abdomen, cardiac ,and PVD **Abdominal Assessment:** **Inspect: contour (flat, scaphoid, rounded, protuberant) and symmetry, striae (if out of nowhere could indicate ascites), dilated veins(significant find and may mean that circulation is being cut off), rashes and lesions, umbilicus (inny or outy, hernia?), enlarged organs, masses, peristalsis (usually hard to see but sometimes can in older pt. when fatty layer is thinned out)** - **Scaphoid is seen in elderly pt. or in malnourished.** - **Protuberant is seen in pregnant women, ascites, or in pops w a beer belly** **Grey Turner's Sign (VERY CRITICAL)** - **Retroperitoneal bleed** - **Call provider immediately** - **Bluish colors around flank areas- suggest hemorrhage** **Now auscultate make sure bladder is empty, use diaphragm, start in right lower quadrant (McBurney's point, most everyone will have some sounds here) and continue in an upside-down C listening for bowel sounds.** - **Hypoactive sounds are expected in some cases such as surgery coming off of anesthesia, medications, and with some inflammation** - **Hyperactive sounds will sometimes occur before bowel is obstructed kind of like a warning sign/cry for help** - **Absent sounds after listening for at least 5 mins in each quadrant occur with peritonitis, severe low potassium, obstruction, paralytic ileus, gangrene** **Now use bell side to listen to aneurisms, bruits (listen over aorta, iliac and femoral arteries. This indicates atherosclerosis), friction rubs, venous hum** - **Aortic aneurism: sausage-like enlargement, strong pulsations. (palpable pulsating mass w/ bruit in around 80% of cases)** **Percussion assesses distention, free fluids, masses, and enlarged organs (spleen/liver)** - **Listen for gastric tymphany, liver dullness, suprapubic dullness, and splenic dullness (ALL NORMAL)** - **Hepatic margins, will feel pop against hand if enlarged** - **CVAT elicit kidney issues, 12^th^ rib, CVA areas- hit hand with fist. This should be painless, if painful this indicates inflammation** - **Fluid wave for ascites. (video we watched in health assessment.) Positive sign will be when you feel a distinct tap on the non-smacking (opposite) hand.** **Palpation light palpation (1-2 cm), deep palpation (4 cm), check for rebound tenderness (when peritoneum becomes inflamed-press-release...pain), use gator chomp when palpating liver, spleen, and kidney** **Stress has a HUGE impact on abdominal health in all ages** - **Now a focused abdominal history (pain, surgery (GB surgery or banding for weight loss), food allergies, weight loss (significant or unintentional), BM frequency/change (being somewhere out of the normal can change this), blood in stool, and medications (such as Ozempic to lose weight causes GI changes)** - **Past health history (illnesses (ED) and chronic illnesses (cancer, IBS), hospitalizations, serious injuries, immunizations (hepatitis A&B, knowing this is important incase coming into contact with eliminations, and medications (overuse of enemas and laxatives can cause problems overtime)** - **Family history, such as genetically linked GI conditions (crohn's, celiac, diverticulitis, polyps, colorectal cancer (FOBT Q year (picks up on internal bleeding problem) and colonoscopy (looks at internal intestine to find polyps (will be removed and tested), cilia, and internal lining)** **Cardiac Assessment:** - **Inspection: look at carotids and jugular (look for jugular vein distention), look for signs related to circulation (edema, cyanosis, etc..)** - **Palpation: pulses, point of maximum impulse (feel apical impulse; 5^th^ ICS, MCL), thrills (vibratory sensation that indicate turbulent blood flow "feel a thrill hear a bruit", feel for thrills over valve areas)** - **Auscultation: can check supine, sitting, left lateral position. Use diaphragm first and then repeat will bell. Carotid bruit; if found, note location, frequency, intensity, quality, duration, and time in cycle. When listening, we use 5 areas; aortic (right 2^nd^ ICS), pulmonic (left 2^nd^ ICS), ERB's point (S1 and S2, left 3^rd^ sternal border and 4^th^ ICS), tricuspid (lower left sternal border. 4^th^ ICS), and mitral (left 5^th^ ICS, medial to midclavicular line) (All People Enjoy Time Magazine) When listening make sure to explain to pt. that listening for a long time does not mean that anything is wrong also ask to breathe normally and to hold breath periodically to enhance sounds that may be difficult to hear** **PVD Assessment:** - **Inspect arms and legs. Look for lesions, skin color** - **Palpate arms and legs for temperature, capillary refill, pulses and edema (posttibial and pretibial, if present measure each leg), and check for calf tenderness** Differences between right and left sided heart failure **Right sided heart failure (cor pulmonale) = fatigue, ascites, enlarged spleen & liver, distended jugular veins, anorexia and complaints of GI distress, swelling in hands and fingers, and dependent edema.** **Left sided heart failure = nocturnal dyspnea, elevated pulmonary capillary wedge pressure, pulmonary congestion (cough, crackles, wheeze, blood-tinged sputum, tachypnea), restlessness, confusion, orthopnea, tachycardia, exertional dyspnea, fatigue, cyanosis** S1 and S2 sounds **S1 = AV valves (tricuspid and mitral valves) closing, "lub" sound, and also the beginning of systole** **S2 = SL valves (aortic and pulmonic valves) close, "dub" sound, and the end of systole and beginning of diastole** Where do you hear murmurs **Heart murmurs can be heard on the chest wall.** **Innocent murmurs occur in children or with pregnancy and are noted during systole** **When there is a murmur during diastole this indicates a pathological disease** **Conditions that cause murmurs:** - **Velocity of blood increases (flow murmur)** - **Viscosity of blood decreases (in anemia)** - **Structural defects in valves.** **S. P. A. S. M. S.** **Stenosis of valve** **Partial obstruction** **Aortic regurgitation** **Mitral regurgitation** **Septal defect** **Grading of murmurs:** - **1 = very faint, easily missed** - **2 = quiet, barely audible** - **3 = moderately loud but easily heard, similar to S1 and S2** - **4 = loud, no thrill present** - **5 = very loud, thrill present** - **6 = heard with stethoscope off chest, thrill present.** PAD and PVD **PAD- Progressive narrowing and degeneration of the arteries. The primary cause is atherosclerosis. Clinical manifestations occur when the vessel is between 60-75% occluded.** **The key features include INTERMITTENT CLAUDICAITION (one or both legs); pain, burning, cramping w/ activity -- resolves with rest -- starts again with activity (walking, jogging, stairs). REST PAIN (toes, arches, heels.) HAIR LOSS ON LOWER CALF/ ANKLE/ FOOT. DRY, SCALY, PALE, MOTTLED SKIN. PALLOR WHEN ELEVATED, RUBOR WHEN LOWERED. DIMINISHED/ABSENT PEDAL PULSE. ROUND PAINFUL "PUNCHED OUT" ULCERS (usually start on toes)** - **Atherosclerosis is the leading risk factor for cardiovascular disease b/c the plaque can dislodge, form thrombus, block vessel, and cause MI aka heart attack. The plaque can also narrow vessel, decreasing the blood flow, which increases the pressure required to pump through (HTN) and the heart works harder.** - **OTHER RISK FACTORS FOR PAD: most significant = cigarette smoking, high cholesterol, HTN, DM, and sedentary lifestyle (non-active). Co-morbidities include = atherosclerosis, chronic kidney disease, morbid obesity, non-traumatic lower leg wound** **Pt. that should be screened: pt. younger than 50 yo with DM and 1 additional risk factor, pt. 50-69 yo with hx. of smoking/nicotine use and or diagnosis of DM. Pt. 70 yo or older, African americans with vascular risk factors, and those with known atherosclerosis (5% of pt. with PAD require amputation (95000 in US)** **Diagnosis for PAD include palpation of peripheral pulses, doppler, ankle brachial index, ultrasound imaging (determines flow of blood/shape of vessels), and ANGIOGRAPHY WHICH IS GOLDEN STANDARD** **ABI scoring: an ABI of 0.90-0.41 or less indicates PAD** - **0.91-1 is borderline cardiovascular risk.** - **0.90-0.71 = mild risk** - **0.70-0.41 = moderate PAD** - **0.40-0.30 = severe PAD, usually with rest pain except in the presence of diabetic neuropathy** - **\