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Respiratory Distress During
Pregnancy
Elaboration of the Given Text
Dyspnea and Pregnancy
During pregnancy, dyspnea accompanied by increased respiratory rate, cough, rales, or respiratory distress raises concerns of possible infection, asthma, pulmonary embolus, or peripartum cardiomyopathy. The middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels is the mediastinum. The right and left pleural cavities, are on either side of the mediastinum and those contain the lungs. The visceral pleura encloses the lung, and the pericardium surrounds the heart.
Cranial Nerve I and Olfaction
A patient's inability to identify the smell of an orange could reflect an abnormality in Cranial Nerve I, the olfactory nerve responsible for the sense of smell. To test the sense of smell, the examiner presents the patient with familiar and nonirritating odors. A person should normally perceive odor on each side and correctly identify the source. Cranial Nerves II and III assess vision and pupillary reaction, while Cranial Nerve VIII tests hearing and balance.
Transient Ischemic Attack (TIA)
A transient ischemic attack (TIA) is now defined as "a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction." Ischemic stroke is "an infarction of central nervous system tissue" that may be symptomatic or silent.
Asteatosis
Physiologic changes of aging include loss of elastic turgor and wrinkling. Skin that appears dry, flaky, rough, and itchy is termed asteatosis. Sun exposure can cause damage to the skin resembling an appearance as weather beaten, thickened, yellowed, and deeply furrowed. Seborrheic keratosis appears as raised, yellowish lesions that feel greasy, velvety, or warty. Painful vesicular lesions in a dermatomal distribution may suggest herpes zoster.
Enlarged Liver
An enlarged liver with a smooth, tender edge suggests inflammation, as in hepatitis, or venous congestion, as in right-sided heart failure. Cirrhosis, hemochromatosis (increased amount of iron in the blood), and lymphoma
produce an enlarged liver with a firm, nontender edge. An enlarged liver that is firm or hard and has an irregular edge or surface suggests hepatocellular carcinoma.
Hypertension in Pregnancy
Chronic hypertension is defined as hypertension documented prior to pregnancy, before 20 weeks, or beyond 12 weeks postpartum. Gestational hypertension refers to elevated blood pressure detected after 20 weeks gestation in the absence of proteinuria. Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage. Primary hypertension, formerly known as essential hypertension, is a disorder which is associated with elevated blood pressure and an unidentifiable cause.
Muscle Groups and Movement
The psoas muscle group and muscles of the abdominal wall assist with flexion. The deep intrinsic muscles of the back assist with extension. The abdominal muscles and intrinsic muscles of the back assist with rotation. Lateral bending uses the abdominal muscles and intrinsic muscles of the back.
Preterm Infants
'Preterm appropriate for gestational age' (AGA) infants are prone to respiratory distress syndrome, apnea, patent ductus arteriosus with left-to- right shunt, and infection. 'Preterm small for gestational age' (SGA) infants are more likely to experience asphyxia, hypoglycemia, and hypocalcemia.
Bursitis
Swelling 1-2 inches below the knee joint and on the medial surface would be suggestive of anserine bursitis. Swelling over the tibial tubercle suggests infrapatellar bursitis. Swelling over the patella suggests prepatellar bursitis. Semimembranous bursitis would be suggested by swelling on the posterior and medial surface of the knee.
Obstructive Lung Disease and Sleep
With obstructive lung disease, the patient experiences orthopnea, dyspnea that occurs when the patient lies down but improves with sitting. Therefore, the patient would use several pillows or sleep upright in a recliner. Orthopnea is seen in obstructive lung disease, mitral stenosis, and heart failure. Paroxysmal nocturnal dyspnea describe episodes of sudden dyspnea that cause the patient to awaken from sleep where the patient must sit up, walk, or stand for it to resolve. Coughing and wheezing may also occur. Angina pectoris commonly creates chest pain or shortness of breath. Jugular venous pressure reflects right atrial pressure and volume status. In cases of cardiac or pulmonary dysfunction, jugular venous pressures usually raise.
Developmental Dysplasia of the Hips (DDH)
DDH presents with limitation of abduction, shortening of the extremity, as the head of the femur does not fit into the acetabulum, and a positive Ortolani's (it clicks when maneuvered). DDH presents with asymmetry of the gluteal folds.
Acute Cholecystitis
Acute cholecystitis presents with right upper quadrant and upper abdominal pain radiating to the right scapular area. It is usually steady and aching. Pain in the epigastric area could be associated with peptic ulcer or dyspepsia. Cancer of the stomach can present with epigastric pain. Acute mechanical colon obstruction presents with pain in the lower abdomen.
Lymph Node Locations
The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are at the angle of the mandible. The occipital lymph nodes are located at the base of the skull posteriorly. The posterior auricular nodes are superficial to the mastoid process.
Menstrual Cycle Abnormalities
Menopause is defined as cessation of menses for 12 months, progressing through several stages of erratic cyclical bleeding. Oligomenorrhea is infrequent bleeding with menses occurring greater than 35-day intervals, or 4-9 menstrual cycles per year. Menorrhagia refers to excessive or prolonged menstrual flow occurring at regular intervals. Metrorrhagia refers to intermenstrual bleeding.
Palpating the Gastrocnemius and Soleus Muscles
The gastrocnemius and soleus muscles are located by palpating the posterior surface of the lower leg.
Nasal Septum Perforation
Perforation of the nasal septum could be caused by trauma, surgery, and intranasal use of cocaine or amphetamines. Nasal polyps obstruct air flow but there is no relationship to nasal septum perforation. Cystic fibrosis or chronic sinusitis are not associated with nasal perforation.
Costovertebral Angle Tenderness
Because the kidney lies directly under the costovertebral angle, tenderness over this area would be related to renal issues such as renal stones or pyelonephritis.
Altered Level of Consciousness
A stuporous patient arouses from sleep after exposure to painful stimuli, verbal responses are slow, and lapses into an unresponsive state. A lethargic patient appears drowsy but opens the eyes, looks at the examiners, answers the questions, and then falls asleep. An obtunded patient opens the eyes and looks at the examiner, but responds slowly and is somewhat confused. A comatose patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli.
Flat Affect
Flat affect occurs in depression, Parkinson's disease, or Alzheimer's disease.
Patellar Roughening and Tendon Injury
Patellar Roughening
Pain and crepitus (crackling sound) over the patella suggests roughening of the patellar undersurface that articulates with the femur. This can be caused by degenerative changes in the patella.
Patellar Tendon Injury
Tenderness over the patellar tendon or inability to extend the knee suggests a partial or complete tear of the patellar tendon.
Swelling and Effusion
Swelling above and adjacent to the patella suggests synovial thickening or effusion of the knee joint.
Ventricular Septal Defect
A heart murmur audible at the lower left sternal border in a child would be suggestive of a ventricular septal defect. This type of murmur is not considered a normal finding in children.
Visualization of Stensen's Duct
To visualize the opening of Stensen's duct, the buccal mucosa opposite the second molar should be examined. Stensen's duct is the duct of the parotid gland, which opens onto the buccal mucosa in this location.
Meningomyelocele
A protrusion of the membranes that cover the spine and the spinal cord itself, through a defect in the bony encasement of the vertebral column, is known as a meningomyelocele.
Shoulder Stabilizers
Static stabilizers of the shoulder are the bony structures of the shoulder girdle, the labrum, the articular capsule, and the glenohumeral ligaments. Dynamic stabilizers are the SITS muscles of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis).
Epispadias
With inspection of the male infant's penis, the urethral orifice appears on the dorsal surface of the glans, which is consistent with epispadias.
Acute Lymphoblastic Leukemia
The majority of children diagnosed with the most common form of leukemia, acute lymphoblastic leukemia, go into remission and remain symptom-free when treatment is complete, with an 85% disease-free survival rate.
Eye Examination Techniques
Cover-uncover test: Assesses coordination of eye muscle movement when one eye is covered. Snellen eye chart: Assesses visual acuity. Ophthalmoscope: Used to visually assess the fundus of the eye. Pupillary reaction: Tests the ability of the eyes to react to light and accommodate.
Corneal Reflex
Touching the cornea and assessing for a reflex assesses cranial nerve V (sensory).
Tibial Tendinitis
Tenderness along the posterior medial malleolus suggests posterior tibial tendinitis.
Cystourethrocele
When the entire anterior vaginal wall, together with the bladder and urethra, is involved in a bulge, a cystourethrocele is present.
Tachypnea and Fever
In children, heart and respiratory rates will increase with fever. For every degree of fever, the respiratory rate will increase 3-4 breaths/minute and the heart rate will increase 8-10 beats/minute.
Trichomonal Vaginitis
A profuse, yellowish, green vaginal discharge that is malodorous is most consistent with trichomonal vaginitis.
Plantar Reflex and Spinal Segments
Absence of movement of the big toe when stroking the lateral aspect of the sole from the heel to the ball of the right foot is suggestive of a pathological lesion in the lumbar 5 and sacral 1 spinal segments.
Strabismus Assessment
Strabismus, or misalignment of the eyes, can be detected using the cover- uncover test and the Hirschberg test (corneal light reflex).
Indirect Inguinal Hernia Palpation
To palpate an indirect inguinal hernia in a woman, have her stand and palpate in the labia majora and upward to just lateral to the pubic tubercles.
Exophthalmos and Graves' Disease
Bilateral exophthalmos (abnormal protrusion of the eye) suggests Graves' disease, a form of hyperthyroidism.
Preterm Labor
If regular uterine contractions occur prior to 37 weeks gestation, this could be a sign of preterm labor.
Global Aphasia
Explanation
Global aphasia is a form of aphasia in which the person has difficulty speaking and understanding words and is unable to read or write. In this condition, the person experiences significant impairment in both language production and language comprehension.
Orthostatic Hypotension
Symptoms
Symptoms of orthostatic hypotension include lightheadedness, weakness, unsteadiness, and visual blurring. Syncope (fainting) occurs in 20% to 30% of patients. Respiratory rate greater than 30 is not a symptom of orthostatic hypotension.
Cystic Fibrosis in Children
Early Manifestations
The earliest recognizable clinical manifestations of cystic fibrosis in a child include clubbing, frequent respiratory infections, and rectal prolapse.
Visual Acuity Assessment
E Chart
The E chart is the most effective method to use when assessing visual acuity in young children. The child can tell the examiner which direction the E is pointing, which is more appropriate than the Snellen test that requires the child to identify letters of the alphabet.
Assessing Conjugate Gaze
The most effective method to use when assessing conjugate gaze in young children is the use of the cover-uncover test and the corneal light reflex test.
Deltoid Muscle Strength Assessment
The nurse practitioner instructs the adolescent to hold his arms against his lateral upper legs against resistance to assess the strength of the deltoid muscle.
Third Nerve Palsy
Ptosis of the left eye would be suggestive of third nerve palsy (CNIII) - Oculomotor nerve.
Fetal Lie and Presentation
Vertical Lie
If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie.
Transverse Lie
If the cephalic prominence is not on the same side as the small parts, then the fetus is most likely in transverse lie.
Vertex Presentation
If the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation.
Face Presentation
If the cephalic prominence is on the same side as the back, then the head is extended, and the fetus is in face presentation.
Post-Streptococcal Glomerulonephritis
The substances found in the urine of a child suspected of having post- streptococcal glomerulonephritis are blood and protein.
Muscle Strength Terminology
Quadriplegia
Quadriplegia means the inability to move or paralysis of all four limbs.
Hemiparesis
Hemiparesis refers to weakness of one half of the body.
Paresis and Plegia
Impaired strength is called weakness or paresis. Absence of strength is called paralysis or plegia.
Weber Hearing Screening Test
The Weber hearing screening test can detect unilateral conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss).
These abnormal stool characteristics are due to the inflammation and damage caused by Crohn's disease in the digestive tract.
In addition to the bloody, mucoid, or purulent stool, Crohn's disease can also cause thin, pencil-like stools. This is due to an "apple-core" lesion in the sigmoid colon, which can lead to obstruction and altered stool shape.
Constipation can also occur in Crohn's disease, resulting in hard, dry stools. In the presence of hemorrhoids, the stool may appear blood-streaked.
Glossitis and Oral Inflammation
Glossitis
Glossitis is a condition characterized by a sore, erythematous (reddened), and smooth tongue. This is a general inflammation of the tongue.
Other related oral conditions include:
Gingivitis: Inflammation of the gums Stomatitis: Inflammation of the mouth, including the mucous membranes and lips Candidiasis: A yeast infection of the mouth, presenting with yellowish- white patchy lesions on the tongue and in the mouth
Venous Hum During Pregnancy
During pregnancy, a venous hum, or continuous mammary souffle, may be auscultated (heard) at the second or third intercostal space at the sternal border. This is due to the increased blood flow through the normal vessels during pregnancy.
The mammary souffle is commonly heard in late pregnancy or during lactation. It is typically both systolic and diastolic, though only the systolic component may be audible.
Anthropometric Measurements
Anthropometric measurements are a set of noninvasive, quantitative techniques used to assess an individual's body composition. These measurements include:
Height and weight Body mass index (BMI) Basal metabolic rate (BMR)
Vital signs, such as blood pressure, pulse, and respiration, are considered physiologic measurements and are not part of the anthropometric assessment.
Cognitive and Language Development
The cognitive and language development between twelve years and adulthood follows the formal operational stage of Piaget's stages of development.
Cephalohematoma and Jaundice
A cephalohematoma is a collection of blood between the skull bone and the periosteum (the membrane covering the bone). Infants with a cephalohematoma are at an increased risk of developing jaundice.
This is due to the breakdown of red blood cells within the hematoma, which can lead to an increase in bilirubin levels and subsequent jaundice. Cephalohematomas do not increase the risk of infections.
Acute Pyelonephritis
Acute pyelonephritis is characterized by flank pain, fever, and chills. These symptoms are consistent with a kidney infection.
In contrast, renal or ureteral colic (kidney stones) usually presents with sudden-onset flank or groin pain, but does not typically include fever and chills. Urethritis in men presents with painful urination without frequency or urgency, and acute prostatitis presents with frequency, urgency, and dysuria.
Lichenification
Lichenification is a skin condition characterized by thickening and roughening of the skin, with increased visibility of the normal skin furrows (grooves on the surface of the epidermis).
This is in contrast to skin atrophy, which involves thinning of the skin with loss of normal skin furrows. Excoriation refers to abrasions or scratch marks on the skin, and the burrow of a scabies lesion includes small papules, pustules, lichenified areas, and excoriations.
Deep Tendon Reflexes and Spinal Cord Levels
The segmented levels of the deep tendon reflexes are:
Ankle: Sacral 1 Knee: Lumbar 2, 3, & 4 Supinator and biceps: Cervical 5 & 6 Triceps: Cervical 6 & 7
An abnormal reflex in the right biceps would be consistent with a pathological lesion at the cervical 5 and 6 spinal cord levels.
The anterior cruciate ligament (ACL) prevents the tibia from sliding forward on the femur, and the posterior cruciate ligament (PCL) prevents the tibia from slipping backward on the femur.
The medial and lateral menisci are fibrocartilaginous discs that cushion the action of the femur on the tibia.
Comatose Patient Assessment
When assessing a comatose patient, the nurse practitioner should not dilate the pupils, as pupillary reaction is the single most important clue to the underlying cause of the coma.
Shoulder Joint Anatomy
The glenohumeral joint is where the head of the humerus articulates with the shallow glenoid fossa of the scapula. The acromioclavicular joint is where the lateral end of the clavicle articulates with the acromion process of the scapula. The sternoclavicular joint is where the medial end of the clavicle articulates with the upper sternum.
Shoulder Muscle Groups
The axioscapular group of muscles pulls the shoulder backward and rotates the scapula.
The scapulohumeral group of muscles rotates the shoulder laterally, including the rotator cuff, and depresses and rotates the head of the humerus.
The axiohumeral group produces internal rotation of the shoulder.
The serratus anterior draws the shoulder blade forward.
Ankle Joint Anatomy
The ankle is a hinge joint formed by the tibia, fibula, and the talus. The tibia and fibula act as a mortise, stabilizing the joint while bracing the talus.
Paranasal Sinuses
The paranasal sinuses include:
Maxillary sinuses: Located around the nasal cavity Frontal sinuses: Located above the eyes Ethmoidal sinuses: Between the eyes Sphenoidal sinuses: Located just behind the ethmoidal sinuses
Foot Dorsiflexors
The dorsiflexor muscles in the foot include the anterior tibial muscles and the toe extensors.
Renal Adaptation in Newborns
In the neonate, the kidneys are structurally complete but physiologically immature. They have an inability to concentrate urine and adapt to fluid and electrolyte stress, leading to an increased risk of metabolic acidosis.
Breast Exam and Mass Mobility
A mobile mass that becomes fixed when the arm relaxes is attached to the ribs and/or intercostal muscles. If the mass becomes fixed when the hand is pressed against the hip, it is attached to the pectoral fascia.
Sinus Arrhythmia in Children
Sinus arrhythmia, where the heart rate varies with inspiration and expiration, is a normal finding in children and does not require further evaluation or referral.
Colorectal Cancer Screening
The U.S. Preventive Services Task Force recommends screening for colorectal cancer with:
Colonoscopy every 10 years Sigmoidoscopy every 5 years with high-sensitivity fecal occult blood tests (FOBTs) every 3 years FOBTs every year, beginning at age 50 through age 75 years
Routine screening is not recommended for adults aged 76 to 85 years.
Great Saphenous Vein Anatomy
The great saphenous vein, which originates on the dorsum of the foot, joins the femoral vein of the deep venous system below the inguinal ligament.
Articular Disease
Articular disease typically involves swelling and tenderness of the entire joint, limiting both active and passive range of motion due to either stiffness or pain. Extra-articular disease typically involves selected regions of the joint and types of movement.
Abdominal Percussion
When percussing a protuberant abdomen, tympany is audible. This is consistent with the following conditions:
Intestinal obstruction Increased intestinal gas production Paralytic ileus
A large solid tumor would give a dull sound on percussion.
Glasgow Coma Scale
The Glasgow Coma Scale assesses motor responsiveness, verbal performance, and eye opening to appropriate stimuli. It is used to gauge the depth and duration of coma and impaired consciousness. It does not include cranial nerve, auditory, or pupillary responses.
Forefoot Abnormalities in High-Heeled Shoes
Women who wear high-heeled shoes with narrow toe boxes are at risk of developing the following forefoot abnormalities:
Hallux valgus Metatarsalgia Morton's neuroma
Achilles tendinitis is more commonly associated with runners and affects the posterior foot, not the forefoot.
Assessing Coordination
To assess coordination, observe the patient's performance in the following:
Rapid alternating movements Point-to-point movements Gait and other related body movements Standing in specified ways
Walking heel-to-toe in a straight line is an example of observing the patient's gait.
Lateral Epicondyle of the Humerus
A small, tuberculated eminence, curved a little forward, and giving attachment to the radial collateral ligament of the elbow-joint is referred to as the lateral epicondyle of the humerus.
Neurological Symptoms
Seizure
A seizure is an uncontrolled electrical activity in the brain that may produce minor physical signs, thought disturbances, or disturbed motor activity, or a combination of symptoms.
Dystonia
Dystonia is a neurological disorder that causes involuntary muscle spasms and twisting of the limbs.
Bradykinesia
Bradykinesia is the term used to describe the impaired ability to adjust to one's body position, noted in patients with Parkinson's disease.
Tremor
A rhythmic oscillatory movement of a body part resulting from the contraction of opposing muscle groups is a tremor.
Infant Tracking
When assessing tracking movements in an infant, the nurse practitioner would observe how well the infant tracks the nurse practitioner's face.
Palmar Grasp Reflex
In infants, the palmar grasp reflex ceases after 4 months. Persistence beyond this time suggests pyramidal tract dysfunction.
Whiplash Injury
In patients with mechanical neck pain with whiplash, the paracervical pain and stiffness begins the day after injury and may be accompanied by occipital headaches, dizziness, and malaise.
Peripheral Nerve Fibers
Most peripheral nerves contain both sensory (afferent) and motor (efferent) fibers.
