Lecture 4

• Subjective data

  appetite, dysphagia, food intolerance, abdominal pain, nausea and vomiting, bowel habits
• When do you worry

  When stool is black and tarry, grey or red. Looks with occult blood, hepatitis hepatitis, localized bleeding; frank bleeding
• subjective data

  usual bowel, change in bowel habits, rectal bleeding, blood in stool, medications, rectal conditions, family history, self-care behaviours
• Objective data

  inspection, auscultation, percussion, palpation
• tips to objective data

  lie patient in supine position, arms at side, knees slightly bent; encourage relaxation; lower pants raise shirt; stand on right side of patient; examine painful areas last
• Inspection

  contour (symmetry, skin, umbilicus, pulsations)
• Ascultate

  diaphragm (as high pitched); bowel sounds (all 4 quadrants, start RLQ and go clockwise); vascular bruits (aorta, renal, iliac, femoral)
• vascular bruits

  using bell, should not hear anything
• bowel sounds (normal)

  hold on skin lightly, should hear gurgling (every 5-15 secs), bubbling clicks,
• bowel sounds (absent)

  no bowel sounds after listening for full 5 minutes
• bowel sounds (sluggish noise)

  3 of fewer per minute
• bowel sounds (hyperactive)

  prolonged gurgling
• Why auscultate before palpating and percussing

  sends body into relaxation. Palpating and percussing may active bowel movements (stimulate) and give false noises
• Percuss

  percuss all 4 quadrants (looking to dullness or tympany). Tympany over hollow, fluid-filled organs (stomach); dullness over dense organs
• Palpate

  light 1cm, all four fingers together, gentle rotary motion, sliding fingers and skin together, then lift fingers to move to next location,
• what do you search for in palpating


  impressions of skin, musculature, guarding, rigidity
• what do you not look for in palpating

  organs
• developmental considerations of infants/kids

  organs are easier to palpate as there are less mucles, clinical shock risk (smaller, high turnover of water and electrolytes)
• developmental considerations of pregnant peeps

  morning sickness, esophageal reflux
• developmental considerations of older adults

  dry mouth = decrease in taste; esophageal emptying is delayed; gastric acid secretion decreases *drug ascription changes; at risk for dehydration *conserve water reduced and ability to respond to changes in temp; less thirst
• constipation

  age; immobility, hyperthyroid, more medications, less fluid, less fibre, sedentary lifecycle
• Gastrouninary exam

  kidney, ureter, bladder, urethra
• Objective data (GU exam) - inspect

  perianal exam, look for cyst, abcess, polyps, fissures, hemorrhoids, fistula, skin lesions or rashes, prolapse, tumour
• Colorectal screening

  everyone over 50 yrs (fecal occult blood test every 2 years, colonoscopy every 5-10). High risk patients get colonoscopy at 40 yrs or 10 yrs before family members age of onset
• Subjective data of GU exam?

  • voiding/urination (frequency, at night, urgency, hesitancy, colour, odour
  • past GU history (infections, hernias, childhood)
  • sex history
  • MEN: sctorum and testicular history, self exam performed?
• Women subjective data

  urinary symptoms, vaginal symptoms (bleeding, discharge), menstrual cycle, obstetrical history, menopause (HRT), STI risk reduction strategies
• Transgender exam

  exam is relevant to physical genetalia
• objective exam male and female

  palpate lower ab wall/pelvic area over bladder (soft, hard, pain?)

  costrovertebral tenderness, transgender
• palpate

  penis and scrotum, inguinal gland for lesions and lymph nodes
• testicular self-exam

  age 15-49; risk factors are delayed descent of testicle, fam Hx; high cure rate is caught early, T:timing, S: shower, E: examine
• Objective data female

  inspect external genitalia (structural abnormalities, skin conditions like rashes, irritation, lesions, prolapse, infestations)
• Cervical screening

  pap at 21 and every 3 yrs (if normal), tests for abnormal (precancerous/cancerous) cells that are not HPV, STI screening, HPV vaccine
• Skin levels

  epidermis: thin but tough; dermis: supportive layer; subcutaneous layer: adipose tissue
• What is skin for

  protection, prevention of penetration, perception, temperature regulation, identification, communication, wound repair, absorption anad excretion, production of Vit D
• older adult skin

  thinning skin, less hair, slower nail growth, temperature dysregulation, loss of elasticity, puritis, loose elastin, collagen, subcutaneous fat, muscle tone, lower number of sweat glands and sebaceous glands
• pregnancy and skin

  connective tissue becomes fragile, ab, arm, breast and thighs
• infants and kids (skin)

  functions are not fully developed, thin, elastic, more permutable (loss of fluid, chemical absorption, temp regulation does not work)
• subjective data (skin)

  history (age, development stage, concens/changes, allergies, irritability level, length of time)
• Questions about skin

  medications, hair loss, change in nails, environmental/occupational
• DARP?

  data, analysis, response, plan