Nursing Exam 2

mottling & causes

**irreversible -bluish marbling -often occurs in light-skinned pts, especially when cold -can occur near time of death due to circulatory changes-one of first signs when death is imminent-starts in toes goes up

signs of venous insufficiency (peripheral vascular)

**issues with it coming back to heart color-normal or cyanotic (hint of blue) temperature-normal pulse-normal edema- often marked skin changes-brown, pigmentation around ankles

RLQ organs

cecum appendix right ovary right ureter right spermatic cord lower portion kidney

during temp alterations what increases

cellular metabolism oxygen consumption HR respiratory rate

clubbing & cause

chronic lack of oxygen abnormal curving of the nails that is often accompanied by enlargement of the fingertips

everyday factors affecting BP

stress age ethnicity gender daily variation medications smoking activity/weight

Striae

stretch marks

carotid artery

supplies oxygenated blood to head and neck palpate one side at a time

guidelines for measuring VS

always your responsibility equipment working & have everything you need know your patient minimize environmental factors systematic approach(work your way down)

distention

swelling

Murmurs

swishing/blowing sounds created by abnormal, turbulent flow of blood in the heart

core temperature

temperature of the deep tissues

Peripheral pulse sites

temporal, carotid, brachial, radial, ulnar, femoral, popliteal, posterial tibial, dorsalis pedis

palpate abdomen for

tenderness, distention, or masses light (1-2 in, smooth, gentle dipping motion) deep ( 1-3 in, specific organs/deeper masses) **systematic approach aortic pulsation

squamous cell carcinomas

appears on non exposed areas&mucosal surfaces usually (more frequent, grows more rapidly) scaly, crusted/ulcerated lesions can metastasize in lymphnodes

ABCD's with malignacies

asymmetry border irregularity color (black, grey) diameter- shouldn't be bigger than head of eraser

Aspects of knowing the patient include

avoiding assumptions focus on patient engage in caring relationship that reveals info and cues that facilitate critical thinking and clinical judgments

blood pressure

the force exerted on the walls of an artery by the blood under pressure from the heart

thermoregulation

the maintenance of body temp within a range that enables cells to function efficiently

arcus senilis

thin white ring along the margin of the iris

4 C's of communication

clear concise correct complete

Bloom's Domains of Learning

cognitive- the why/when affective- feelings (teaching) psychomotor(skills)- the how

third most common cancer

colorectal cancer

head-to-toe approach when conducting exam

compare sides for symmetry assess body systems most at risk for being abnormal offer rest periods as needed perform painful procedures at end be specific when recording assessments record quick notes during larger notes at end

heat exhaustion

condition resulting from environmental heat exposure and excessive loss of fluid (diaphoresis) through sweating

atrophy

to waste away (muscles atrophy when not used)

indurated

hardened, when palpating skin feeling for texture

RUQ organs

liver gallbladder duodenum head of pancreas part of kidney adrenal gland part of ascending and transverse colon

Hypotension & values

low blood pressure < 90/60

osteopenia & risks

low bone mass of hip risk for osteoporosis, fractures, complications later in life

2 major heart sounds

lub- S1, closure of mitral&tricuspid valves at start of systole dub- S2, closure of aortic&pulmonic valves at end of systole

Barrell Chest

lungs overfilled with air; lungs must work harder seen in COPD & asthma patients upper chest puffed out

knee-chest position

lying face down; knees brought to chest

dorsal recumbent position

lying on back, knees up

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

lateral recumbent position

lying on right or left side

capnography

measurement of exhaled CO2 throughout exhalation

apical pulse & location

measurement of heart beat location: midclavicular, 5th intercostal space

antipyretics

medications that reduce fever

percussion

method of tapping body parts with fingers, hands, or small instruments determines location, size and density of structures

MMSE

mini-mental state examination -orientation to time (date) -registration (say 3 words, have them say back) -naming (point to object, what is this) -reading (read sentence, do what is says)

diastolic pressure

minimum arterial pressure during diastole heart relaxes

Depression

mood disturbance characterized by feelings of sadness & despair

malignant melanoma

most dangerous generally starts as mole black/dark brown patches on skin that may appear uneven in texture, jagged, or raised

vital signs

most frequent/routine measurements obtained pulse, temp, BP, respiratory rate, oxygen saturation, pain

ventilation

movement of air in and out of the lungs

Peristalsis

movement of contents through the intestines

chest excursion

movement of the thoracic diaphragm during breathing (remember demonstration in class)

Stenosis

narrowing

5 main functions of the skeletal system

protection movement support heat circulation

touch does what..

provides comfort creates connection

edema

puffy swelling of tissue from the accumulation of fluid

cardiovascular system- 3 types of circulation

pulmonary-heart and lungs systemic-organs and body tissues minus H&L coronary-movement of blood through heart tissues only

PERRLA

pupils equal round reactive to light accommodation

character of pulse when assessing

rate rhythm strength quality

paronychia

red, inflamed areas on nail bed

basal cell carcinomas

reddish, crusted, raised lesion most common form of skin cancer sun exposure generally doesn't spread

Metacommunication

refers to all factors that influence communication **sum of verbal and nonverbal communication**

intrapersonal relationship

relationship with one's self and mind

heart placement

right side is anterior located in 3rd, 4th, and 5th intercostal spaces

Bradycardia & value

slow HR < 60 bpm in adults

LUQ organs

stomach spleen pancreas left lobe liver portion of kidney portion of traverse&descending colon

dementia

generalized impairment of intellectual functioning

alopecia

hair loss (genetic tendencies, endocrine disorders)

snycope

"Passing out", loss of consciousness or fainting due to inadequate circulation to brain

performing BSE (how)

**Inspection in front of a mirror** •hands on hips, press down firmly •contracts the chest wall muscles, enhances any breast changes •look for changes in size, shape, contour, dimpling, redness, scaliness •Turn to each side for side views, looking for flattening •Palpate sitting/standing (underarm) for lumps or changes

BSE

**breast self-examination monthly examination-check for lumps, changes in size/shape, or any abnormality *early detection is key**

Risk factors for breast cancer (women)

**can control** smoking, lack of preventative care, postmenopausal obesity, activity level, alcohol consumption **can't control** family history, recent oral contraceptive use, >40, early onset period, late menopause, no full-term births, births after 31

sensory function testing

**eyes closed, test bilaterally light touch, pinprick, temp, vibration comparing sides-proximal/distal, right/left, dermatome(way nerves run around the body)

Central cyanosis **also called.. & where to assess

**hypoxia -low oxygen -lips, tongue, mucous membranes

cardiac assessment steps

**inspection, palpation, & auscultation -if possible, work from your pt's right side -inspect the neck for pulsations -inspect the precordium(tissue over H&L) for pulsations -palpate the carotid arteries& precordium for pulsations -auscultate the carotid arteries with the bell of the stethoscope -palpate the peripheral pulses

Signs of arterial insufficiency (peripheral vascular)

**not flowing where it needs to Color-pale; worsened by elevation of extremity; dusky red when extremity is lowered Temperature-cool, blood flow blocked to extremity Pulse-decreased or absent Edema-absent or mild Skin changes-thin, shiny skin; decreased hair growth; thickened nails

holes

**primary skin lesion -open areas, extend into dermis

Nodules

**primary skin lesion elevated mass, deep, firm, 1-2 cm

pustule

**primary skin lesion elevation of skin containing pus

papule

**primary skin lesion like zit without the whitehead, solid, raised, firm

wheal

**primary skin lesion raised red skin lesion due to interstitial fluid (hives, bite from mosquito when allergic)

tumor

**primary skin lesion solid mass, extends deep down, much greater than 1-2 cm

Koilonychia *aka..

**spoon nail caves inward (anemia)

best time for self examination of male genitalia

*15 & older-best after shower-scrotum less thick

peripheral arteries and veins

- Assess the adequacy of blood flow to extremities by measuring arterial pulses&inspecting the condition of the skin and nails - Assess the integrity of the venous system - Assess the arterial pulses in the extremities to determine sufficiency of the entire arterial circulation

musculoskeletal assessment includes

-ROM -gait -posture -muscle tone

adventitious sounds

abnormal breath sounds

Assessment of thorax and lungs

-assess respirations; counting the rate and observing the rhythm, depth, & symmetry of chest movement -palpate chest for tenderness, masses, or crepitus; chest excursion, and tactile fremitus

petechiae

-broken capillaries under the skin showing as tiny, pinpoint red or reddish-purple spots

abnormal breath sounds

-diminished breath sounds -misplaced breath sounds- aginal breathing is abnormal-not breathing effectively -adventitious breath sounds

peripheral cyanosis & where to assess

-exposure to cold (come in from outside, lips blue) -extremities, lips

jaundice cause & where to assess

-increased deposit of bilirubin in tissues -skin is orange/yellow -often related to liver disorders •Sclera-whites of eyes-typically first notice •Mucous membranes •Hard palate of the mouth •Palms and soles, skin in general

ptosis

abnormal drooping of upper eyelid over the pupil; edema or impairment

neurological assessment includes

-level of consciousness -mentation-mental state, person, place, time, situation -pupil reaction -gait and balance -limb movement -extremity strengthneurological

Borborygmi

-loud, gurgling bowel sounds signaling increased motility -early bowel obstruction, gastroenteritis, diarrhea

pre-assessment abdomen

-pt relaxed -warm room -bladder empty -supine or dorsal recumbent

erythema & causes where to assess

-reddened area due to increased visibility of oxyhemoglobin caused by dilation or increased blood flow -rashes, skin infections, prolonged pressure on skin -application of heat or cold, alcohol intake, fever -face, area of trauma, common pressure site injuries, sacrum

Scoliosis

abnormal lateral curvature of the spine

respiratory assessment includes

-respiratory rate and rhythm -depth (deep, shallow, normal) -effort (labored or non-labored) -quality (whistling, gurgling) -cough: Yes or No -if yes, Productive Yes or No -breath sounds -sputum-yes cough, yes productive, what color sputum -nasal patency- one side at a time (how open)

when assessing skin- cyanosis & due to..

-skin is blue-grey -hypoxia, exposure to cold, heart/lung disease

when assessing skin- pallor & due to..

-skin is pale -poor circulation, low hemoglobin level (anemia) -

loss of pigmentation

-vitiligo -congenital or autoimmune condition causing lack of pigment -patchy areas on skin over face, hands, arms

flushing & causes

-widespread, diffuse area of redness -Fever, anxiety, high room temp, sunburn -Polycythemia (an abnormal increase in RBC) -vigorous exercise -certain skin conditions; rosacea

Osteoporosis teaching strategies

-women/men 65+ routine screening -proper exercise regimen, 3+ times weekly -added calcium & vit D -body mechanics, ROM exercises

neurological assessment-reflexes scale

0: no response 1+: sluggish/diminished 2+: active/expected response 3+: more brisk than expected, slightly hyperactive 4+: brisk and hyperactive with intermittent or transient clonus-going up, spasming, coming back down

normal respiration rate

12-20 breaths per minute

Normal BP value

120/80 for adults

typical nail plate angle is

160 degrees

Grading pupil size

2-3 norm shine light-constrict take away-dilate to norm

middle adult age range

35-64

pulse norm value

60-100 bpm

older adult age range

65+

Spiritual Health

achieved when a person can find a balance between life values, goals, and belief systems and those of others

delirium

acute confusional state

dysrhythmia

Abnormal heart rhythm

bradypnea

Abnormally slow breathing rate; less than 12 breaths per minute

carotid pulse site

Along medial edge of sternocleidomastoid muscle in neck

dorsalis pedis pulse site

Along top of foot, between extension tendons of great and first toe

aphasia & 2 different types

affects language/speech sensory (receptive)-able to talk but words don't make sense Motor (expressive)-able to understand but can't get words out

auscultation sound characteristics

frequency loudness quality duration

Pyrogens

Bacteria and viruses that elevate body temperature

femoral pulse site

Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine

factors affecting body temp

age, exercise, hormone level ^, stress, environment, circadian rhythm, temp alterations (ex-fever)

Crepitus

air escapes & is underneath the skin

diffusion

air is exchanged between alveoli and lungs

peripheral vascular system consists of

Carotid arteries Jugular veins Peripheral arteries and veins Lymphatic system

Perfusion

Circulation of blood within organs and tissues

3 types of loss when it comes to hearing acuity

Conduction- problem conducting sound waves throughout ear (hearing loss, inflamed ear canal, tear in ear drum) Sensorineural- inner ear & auditory nerve-can't get to inner ear, interrupted, auditory nerve is damaged Mixed- combination of 2

LLQ organs

Part of descending colon Sigmoid colon Left ovary Left ureter Left spermatic cord lower portion kidney

orthostatic hypotension (postural hypotension)

Decrease in blood pressure related to positional or postural changes from lying to sitting or standing

Jugular veins (internal & external) **what indicates abnormality

Drains head and neck (external) drains brain (internal) **if external jugular is visible when sitting/standing

Turgor

Elasticity of the skin can be indicator of hydration status

Tachycardia & value

Elevated heart rate > 100 bpm in adults

Lordosis (swayback)

Excessive curvature in the lumbar portion of the vertebral column

brachial pulse site

Groove between biceps and triceps muscles at antecubital fossa

most important risk factor for cervical cancer

HPV infection

cardiac assessment includes:

HR & rhythm (regular/irregular) central and Peripheral Pulses capillary Refill-checking for profusion, less than 3 seconds=norm. skin temperature in relation to circulation

ISBAR

Identify Situation Background Assessment Recommendation

posterior tibial pulse site

Inner side of ankle, below medial malleolus

Physical Assessment Techniques

Inspection Palpation Percussion Auscultation

shivering

Involuntary body response to temperature differences in the body

nystagmus

Involuntary rapid eye movements

Glasgow Coma Scale

LOC, scale, best-15, comatose- 8 or less, totally unresponsive-3 -eyes opening(spontaneous, speech, pain) 4-1 -verbal response(5-1) -best motor response (6-1)

Carotid bruit

Narrowed blood vessel creates turbulence, causes blowing/swishing sound. **abnormal finding-at risk for stroke

nonshivering thermogenesis

Occurs primarily in neonates cannot shiver, a limited amount of vascular brown adipose tissue present at birth can be metabolized for heat production

Temporal pulse site

Over temporal bone of head, above and lateral to eye

pulse (& is indicator of..)

Palpable bounding of blood flow noted at various points on the body **indicator of circulatory status**

fever (also known as...)

Pyrexia elevated body temperature heat loss mechanisms unable to keep pace with excessive heat production

Radial pulse site

Radial or thumb side of forearm at wrist

Tachypnea

Rapid breathing; more than 20 per minute

ventilation assessment

Respiratory rate: breaths/minute Ventilatory depth: deep, normal, shallow Ventilatory rhythm: regular/irregular

Excoriation

Skin sore or abrasion produced by scratching or scraping

scale for assessing peripheral arteries

Strength measurement •0: absent, not palpable •1: pulse diminished, barely palpable •2: expected/normal •3: full pulse, increased •4: bounding pulse

BSE (palpate lying postion)

To examine right breast, place the right arm behind the head •Use the pads of three middle fingers on the left hand to feel for lumps in the right breast •Use overlapping small circular motions to feel breast tissue •Move around the breast, using one of the three techniques (up/down, circular, wedge)

Osteoporosis

a condition in which the bones become fragile and break easily, loss of bone density

range of joint motion-hip

ball and socket femur, pelvis flexion, extension, abduction, adduction, rotation, circumduction not as great a range of movement as shoulder, more stable

range of joint motion-shoulder

ball and socket humerus, scapula flexion, extension, abduction, adduction, rotation, circumduction greater range of movement that hip, not as stable

popliteal pulse site

behind the knee in the popliteal fossa

supine position

belly up

frostbite

body is exposed to subnormal temps, ice crystals form in cells and permanent circulatory & tissue damage occur

heat stroke

body temp >104 accompanied by hot, dry skin and CNS abnormalities (delirium, convulsions, coma) has high mortality rate

Normal breath sounds

bronchial breath sounds-air moving through trachea close to the chest wall -bronchovesicular-air moving through larger airways -vesicular-air moving through smaller airways

Ecchymosis & causes

bruised (Blue-green-yellow) area -may be seen anywhere on body -color may vary based on age of injury -trauma, internal bleeding, side effect of medication, bleeding disorder

Hyperopia (farsightedness)

can see far but not near

Myopia (nearsightedness)

can see near but not far

factors affecting arterial BP

cardiac output peripheral resistance blood volume viscosity elasticity

adventitious breath sounds

crackles-(rales) high pitched, cough & does not clear, fluid, pneumonia, NEVER normal, on inspiration rhonchi-rumbling, coarse, sounds like snore inside chest, can usually have them cough & clears or suction wheeze-usually louder during expiration, doesn't go away with cough, whistling sound pleural friction rub-creaking, grating, like walking on fresh snow

tactile fremitus

created by vocal cords transmitted through lungs to chest wall palpation

hypoxemia

decreased level of oxygen in the blood

hypotonicity

decreased muscle tone; muscle feels flabby, soft, boggy

pulse pressure & norm value

difference between systolic and diastolic pressure normal: 40-60 mmHg

pulse deficit

difference between the apical and radial pulse rates

orthopnea

difficulty breathing when lying down, relieved by sitting/standing

pt teaching for abdomen

drink water high fiber-low fat diet exercise regularly

ototoxicity

drugs known to damage the ear (auditory nerve) some diuretics & antibiotics some NSAIDs

Kyphosis (hunchback)

exaggerated thoracic curvature

physical assessment of ears consists of

external middle inner

prone position

face down

fever of unknown origin (FUO)

fever with an undetermined cause

febrile

having or showing symptoms of a fever

physical assessment of head & neck include

head eyes ears nose mouth pharynx neck

physical assessment of head consists of palpating

head/skull - nodules, masses, abnormalities temporomandibular joint (TMJ)

physical assessment of head consists of inspecting

head/skull - position, size, shape, contour facial features - eyelids, eyebrows, nasolabial folds, mouth

hypothermia

heat loss during prolonged exposure to cold, overwhelms ability of body to produce heat classified by core temp measurements

Malignant hyperthermia

hereditary condition in which certain anesthetics (e.g., halothane) cause high body temperatures and muscle rigidity

Hypertension & values

high blood pressure >130/80

range of joint motion-knee

hinge femur, tibia flexion & extension quads and hamstrings move this joint

range of joint motion-elbow

hinge humerus, ulna, radius flexion & extension biceps & triceps move this joint

Hypertonicity

increased muscle tone; retracts, resistance

phlebitis

inflammation of a vein that occurs after trauma to the vessel wall

Conjuctivitis (Pink Eye)

inflammation of the tear ducts

for abdomen assessment what's order of duties & why

inspect, auscultate, palpate can alter frequency&intensity of bowel sounds

sphygmomanometer

instrument to measure blood pressure by auscultation

Goniometer

instrument used to measure joint angles

neurological functions to assess

intellectual function sensory function cranial nerve function motor function

5 levels of communication

intrapersonal interpersonal small group (3-5 people) public electronic (email/text)

5 caring processes

knowing being with(emotionally present) doing for enabling(life transitions:death/life) maintaining belief

auscultation requires

knowledge, good hearing, good stethoscope, concentration and practice

Young adult age range

late teens to mid-late 30's

Splinter hemorrhages

little black lines under nail (trauma)

3 types of touch

non contact- eye contact contact touch- actually touching protective touch-keep them from being harmed (falling)

eupnea

normal, healthy respirations

bowel sounds & how long to listen

normal-soft, gurgling, clicking, occur regularly audible absent hyperactive (borborygmi) hypoactive **5 minutes continuously

sites where you can measure temperature

oral rectal axillary tympanic (ear) temporal

5 P's (peripheral vascular)

pain pallor (color) pulselessness paresthesia (tingling, numbness) paralysis

thrill

palpable vibration on the chest wall sounds like purring of a cat

systolic pressure

peak pressure; heart is contracting

oxygen saturation

percentage of hemoglobin that is bound to oxygen

transpersonal relationship

person is connected with God, an unseen force, or a higher power.

interpersonal relationship

person is connected with others and the environment

Convection

transfer of heat away by air movement

evaporation

transfer of heat energy- liquid to gas

Conduction

transfer of heat from one object to another with direct contact

Radiation

transfer of heat from the surface of one object to the surface of another without direct contact

ulnar pulse site

ulnar or little finger side of forearm at wrist

caring

universal phenomenon influencing the ways in which people think, feel, and behave in relation to one another **it is a word for being connected**

cranial nerves to know

vagus-movement of vocal cords glossopharyngeal-taste, ability to swallow -sensory/motornormal

diaphoresis

visible perspiration primarily occurring on the forehead and upper thorax

physical assessment eyes

visual acuity - central vision (near and distant) visual fields - peripheral vision extraocular movements - six directions of gaze external eye structures

ausculatory gap

when taking BP, the temporary disappearance of sound in between measurements

Afebrile

without fever

Abdomen quadrants (2)

xiphoid process-upper symphysis pubis-lower

cerumen

yellow, waxy substance in opening of the ear canal (meatus)

patients with vascular inefficiencies should

• avoid tight clothing •sitting/standing for long periods of time •sitting with legs crossed •walk for exercise regularly •elevate feet when sitting •no smoking cigarettes, pipes, cigars or other nicotine products (vasoconstriction) •monitor blood pressure

risk factors for colorectal cancer

•40 or older​ •High-fat, low fiber diets •Obese, physically inactive •Smoking •Alcohol consumption •A personal or strong family history of colorectal cancer, polyps, or chronic inflammatory bowel disease​

signs of possible breast cancer

•Changes in skin texture (orange peel skin) •Retraction or indentation of nipple •Discharge from nipple •Atypical fullness and/or puckering •Bleeding •Asymmetry

skin assessment includes

•Color •Temperature-touch •Turgor •Integrity-intact? Broken open somewhere? •Texture-flaky and dry? Smooth? •Lesions-open areas •Mucous Membranes-look in mouth, are they hydrated? Sores? Ulcers?

during breast palpation (normal&abnormal)

•Normal - dense, firm, elastic •Abnormal - masses, lesions that are hard, fixed, non-tender, irregular, one-sided •Common benign finding - fibrocystic disease (bilateral, lumpy, painful, soft, moveable)

male genitalia assessment includes

•Penis •Scrotum and testes •Inguinal ring and canal

the peripheral arteries consists of

•Radial pulse •Ulnar pulse •Brachial pulse •Femoral pulse •Popliteal pulse •Dorsalis pedis pulse •Posterior tibial pulse

breast stages (puberty 8-20)

•Stage 1 - nipple elevation •Stage 2 - breast and nipple elevate as small mound, areola enlarges •Stage 3 - further enlargement •Stage 4 - areola and nipple project into secondary mound •Stage 5 - mature breast

performing BSE (when)

•Timing-fourth through seventh day of menstrual cycle OR right after the menstrual cycle ends •If not menstruating or pregnant, conduct on the same day each month •Palpate standing or sitting (underarm) •Palpate lying position (breast)

palpating the scrotum (normal & abnormal)

•Use thumb and first two fingers •Normal - smooth, rubbery, free of nodules •Abnormal (common symptom of testicular cancer) painless enlargement of one testis and the appearance of a small, hard palpable lump, about the size of a pea, on the front or side of the testicle.

warning signs prostate cancer

•Weak/interrupted urine flow •Inability to urinate •Difficulty starting or stopping urine flow •Polyuria, nocturia, hematuria, dysuria •Pain in lower back, pelvis or upper thighs **Age 50 and older, digital rectal exam and prostate-specific antigen test (PSA) annually

pre-assessment genitalia

•empty bladder •Stand or supine •Warm exam room •Use calm, gentle approach •Offer explanations to each task

breast palpation techniques

•pads of the first three fingers to compress breast tissue gently against the chest wall •Vertical strips •Circular-middle out •Wedge- middle out