Physical Assessment Recognizing normal and Abnormal Head to

Physical Assessment Recognizing normal and Abnormal

Head to Toe • Be systematic and consistent – always the same, every time • Your skill will be recognizing NORMAL • Any ABNORMAL, and you will investigate: acute or chronic? watch it or refer it?

HEENT • Any sagging, drooping or asymetry ★ acute or chronic (“normal for her”)? ★ ANY acute CNS abnormals = REFER CN = abnormalities are RARELY isolated Can she move eyes, puff cheeks, smack lips, stick out tongue, raise eyebrows?

HEENT, continued PEERLA : Opthalmoscope = looking for basic eye anatomy Sclera white Conjuctiva pink and non-draining Ears : “otoscope is optional; basic assessment • Nose: deviated septum are commonly missed Exophthalmia : “bulging eyes” = hyperthyroid?

Exophthalmos

After intervention…. .

Neck and Throat • • Any tenderness? Should have NO palpable lymph nodes Be used to feeling “normal” thyroids Enlarged thyroid = goiter (refer!) Iodine insuffeciency Thyroid disorder Will affect fetal development and BF

Thyroid Disorders

Sinuses Should be Non-Tender

Lymph Nodes

Lymph Node Distribution

Lymph Nodes Should be NON-palpable Should be NON-tender Unilateral enlargement = more ominous ANY enlargement = refer for MD exam! Often cervical are enlarged during illness of ENT. • Axillary and inguinal enlargement= !!!! • • •

Abnormal nodes

lymphoma

Heart Normal V/S abnormal We DO NOT DIAGNOSE! Abnormal = REFER! PMI / APEX evaluation HTN in pregnancy : increase of 30/ 15 points from BASELINE (or 140/90) • Maternal HR = under 115 increased : dehydration, anemia, fatiguue? ? ? • • •

Heart – Find the PMI/ Apex • Listen for one full minute at Apex / PMI

PMI palpation

Basic Auscultation Sites

If You’re Gonna Pick One Spot…. .

Basic Heart Sounds

Mitral Valve Prolapse (MVP)

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Lung Sounds and Breathing • Your ROS will screen for risks here: smoker, chronic bronchitis, asthma? What’s “normal SOB” in pregnancy? SOB: Physiolgic anemia and smaller lung volumes as uterus pushes into diaphram Are we too comfortable with SOB in pregnancy? ?

Lung Field Areas

Areas for Pulmonary Auscultation

Should ONLY Hear Normal • Anything but normal is …. abnormal! • Wheezes- high pitched, often expiratory - the “asthma sound” Rhales and Rhonchi – abnormal sounds present with inflamation and infection Important: do sounds clear when pt coughs?

Abdominal Assessment

Which Organs in Each Quadrant?

Basics of Abdominal Assessment • Auscultate for bowel sounds (+ or -) • Palpate all quadrants for tenderness • Palpate all areas for masses Palpate for : liver, spleen and kidneys Inquire as to any surgeries, if scar(s) noted Round ligament pain is common in 2 nd trimester Suprapubic tenderness = UTI? ?

UTI and Pregnancy • Most common cause of preterm labor (PTL) • If h/o chronic UTI = AT RISK! • Asymptomatic Bacteriuria – risk of ascending! (why we test urine, each visit!) (bladder only partially empties= stasis of urine) • Pylonephritis in pregnancy = requires IV abx! (fever, chills, nausea, malaise……) • CVA tenderness- indicative of pylonephritis • Is “round ligament pain” ureter pain?

CVA tenderness • CVA tenderness – think pylonephritis • A medical emergency! Go to urgent care!

Painful = Sign of Pylonephritis

Other Special Tests Rebound Tenderness = infection! (think appendicitis or peritonitis) refer usually will have fever, but NOT ALWAYS Scratch Test = to find liver borders

Skin and Vessels • Any moles, lesions, bruising, etc for moles or lesions : acute or chronic? any acute onset or changes = refer! normal, non-tenting skin turgor? Varicosities – will worsen during pregnancy! DVT risk!!

Extremities • • Gait even and normal? Overall tone normal? Normal joint ROM? Pt is able to do normal activities? Any history of problems? DVT’s – see separate slide Edema – see separate slide DTR’s and Clonus – see separate slides

DVT’s and Pregnancy • • Pregnancy = Hyper-coaguable state Popliteal pain = be suspicious! May describe as “aches all the time” Homan’s Sign + = refer! One leg bigger than the other (usually calve) Lower extremity =Swollen & warm to the touch DO NOT massage or use heat! REFER!!!

DVT

DVT – present as ankle swelling!

Not Always That Obvious!

DVT’s – Prevent Them! ✓ Counsel patients with desk jobs! ✓ Counsel patients who will take road trip or fly during pregnancy! ✓ Compression stockings – they work ✓ Frequent stretching and flexing of calves ✓ Encourage ambulation and activity post-partally!! ✓ Teach patient that “one sided swelling” is not ok!

Edema • Decreased coloidal pressure = predisposes increased dietary protein can help Decreased venous return / increased vascular congestion (esp. as uterus enlarges) Assess: press into pre-tibial, ankle or shin area Described as pitting or non-pitting Pitting is on a 1+ - 4+ scale Pedal (foot) edema can be severe and painful! Increased DVT risk with severe edema!!

Assessing Degrees of Pitting

Not just how deep, but how long also! (and blanching of indent) • • Slight indent, but resolves rapidly= 1+ Obvious indent / resolves <5 seconds= 2+ 5 -10 seconds for indent to resolve = 3+ Indentation > 15 seconds = 4+ (and for color to return/ blanching resolve, on all of them, as well)

+4 Pitting Pedal Edema

Lower Extremity +4 edema

This is NOT ok!

DTR’s • • • Increased Patellar reflexes = pre-eclampsia s/s Reflexes are graded as 1+- 4+ Fairly subjective; will recognize brisk!! If you’re wondering if they are brisk…. Very little touch is required for true brisk DTR’s

Clonus- an Ominous Sign! • Stand to side of pt • Hold lower leg gently loosely in one hand • Use other hand to dorsi-fled foot up and back (Sort of briskly pulling toes and ball of foot to knee) • Do this quickly • Toe will “tap” back at you, against your hand • THIS IS A SIGN OF IMPENDING SEIZURE!! • Chart “+ clonus noted”, and what you did next!

PIH V/S Pre-eclampsia PIH: • Elevation of BP (>30/15 increase, >140/90) • Edema • Protienuria When you add hyper-reflexia = pre-eclampsia Increased DTR’s (3 -4+) + clonus = seizure is impending! (stroke!) Seizure = eclampsia

Pre-eclampsia Warning Signs • • Increased blood pressure Marked edema (3+ or >) Protienuria (>1+) Increased DTR’s (3+ or >) Clonus + (not always elicited) Headache, blurred vision, “not feeling right” Episgastic (R upper quadrant) pain HELLP labs elevated!!! (liver enzymes / clotting)

Supine Hypotensive Syndrome • BP drops while recumbent / supine • Creates nausea, change in LOC, fetal distress, UC’s, etc. • Mom will report “I feel nauseated” • Mom may become diaphoretic • Assume all women have this! don’t lie prenatal pts supine! Some degree of wedging!