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
