NR304 Assessment ESE Study Guide
1. PVD assessment: ulcers (arterial vs. venous)
a) Arterial deficient ulcers occur on _____?
b) Venous ulcers occur at ______ because of fragile tissue w/ poor drainage.
2. Assessment of legs
a) Color: If peripheral vessels are constricted the skin will be _____.
b) Color: If the vessels are dilated the skin tone will be _______.
c) Color: An elevated leg that is pale indicates?
d) Color: _______ must be reported to the physician immediately.
e) Color: a _____ discoloration over the tibial surface is associated with ____ disease. The color stems from blood leaking out of a vessel.
f) Texture: thickened skin w/ brown discoloration can…show more content…
2. Pain felt upon sudden release of pressure
a) Aortic aneurysm or increased pulse pressure.
b) Place hand above right knee and ask pt to raise the leg to meet your hand. Pain may indicate appendicitis.
c) While palpating the liver ask the pt to take a deep breath. Sharp abdominal pain occurs in pt’s with cholecystitis. (in the RUQ)
d) Pain in the RLQ upon palpation of the LLQ.
4. Light palpation: used to find areas of tenderness. Deep palpation used to find masses and areas of deep tenderness.
a) Flat, rounded, & scaphoid contours. A protuberant abdomen is only normal in pregnancy, obesity, & ascites.
b) Macules, moles, & freckles.
c) Normal bowel sounds (occurring 5-30 times per min) & borborygmi (stomach growling). Normal bowel sounds are irregular, high pitched, gurgling sounds.
d) Hyperactive: loud, high pitched, & rushing. Occur w/ diarrhea & gastroenteritis. Hypoactive: slow & sluggish. Occur after abdominal surgery or bowel obstruction. Bruits pulsatile and blowing. A venous hum is soft, continuous, and low pitched (indicates portal tension). Friction rub is rough grating sound caused by the rubbing together of organs.
e) Flat- short and abrupt
f) Tympany- loud hollow sound
g) Dullness- short, high-pitched.
1. Muscle mass difference: periods of __________ can result in decreased muscle tone.
a) _________ interferes with bone growth and muscle tone.
b) By the age of 80, about _____ of muscle mass is lost.