Nursing

Examples of trans fat

"Partially hydrogenated oils"; commonly found in fried foods and shelf food

Pitch or frequency

(high or low)

Amplitude or intensity

(loud or soft)

Two parts of an assessment:

-Health history -Examination

How to asses the lymph nodes

-be systematic -palpate with pads of fingers -palpate both sides simultaneously -normal: non palpable, non tender

Types of Edema:

-dependent -pitting -due to inflammation/injury -obstruction

Absent, not palpable (Doppler)

0

Pulse diminished, barely palpable (weak)

1+

3 types of assessments and order?

1. General Assessment; across the room 2. Focused Assessmentl why the pt is there 3. Full Assessment; head to toe

How deep is light palpation?

1/2 inch deep

Normal nailed degree

160 degrees

How deep is deep palpation?

2 inch deep

Expected/normal pulse

2+

RN must assess their patient every _____ hours

24

Full pulse, increased (too much fluid)

3+

normal respiration

3x longer than exhalation

Bounding pulse

4+

The point of maximum impulse is located at the

4th - 5th ICS just left of the midclavicular line.

Where is the Point of Maximal Impulse located?

5th intercostal space, left mid-clavicular line

Braden Scale score range

6-23 Lower the score, greater risk

Normal cap refill time

<3 seconds

Movement of extremity away from midline of body

Abduction

A in PERRLA

Accommodation

Example of pustule

Acne, staphylococcal infection

Movement of extremity toward midline of body

Adduction

Define Rinne test

Air conduction greater than bone conduction 2:1

When auscultating the abdomen, listen to

All quadrants

Rule with recording blood pressure

Always record highest blood presses reading

What calves close to cause S2?

Aortic and Pulmonic

What organs are found in the lower right quadrant?

Appendix

Example of atrophy

Arterial insufficiency

pump blood out

Arteries

When assessing two of anything....

Assess at the same time

What does the A stand for in the skin ABCD assessment

Asymmetry

When do you perform painful assessments?

At the end

Where do you pinch to assess turgor?

Back of forearm or sternum

Most common skin abnormality

Basal cell carcinoma

Which side of the stethoscope would you use to listen to the heart and arteries? Vascular sounds

Bell

What does the B stand for in the skin ABCD assessment

Border

Used to predict patients at risk for skin breakdown

Braden Scale

What happens if you feel both carotid arteries at the same time?

Bradycardia

Loud, and high pitched with hollow quality. Expiration lasts longer than inspiration (3:2)

Bronchial breath sounds

Blowing sounds that are medium pitched and intensity. Inspiratory phase equal to expiratory phase

Bronchovesicular breath sounds

blowing sounds best heard between scapulae and anteriorly over bronchioles lateral to the sternum

Bronchovesicular breath sounds

Maintains the health and mobility of the large intestines

Carbohydrates

Major source of energy

Carbohydrates

Simply put, starches and sugars

Carbohydrates

Define pustule

Circumscribed elevation of skin similar to vesicle but filled with pus, varies in size

What organs are found in the lower left quadrant?

Colon

What does the C stand for in the skin ABCD assessment

Color

Define screening exam

Community setting or in doctor's office

Define strabismus

Congenital- both eyes do not focus on an object simultaneously; cross eyed

The Glascow Coma Scale rates the level of what?

Consciousness

What is a thrill?

Continuous palpable sensation that resembles the purring of a cat.

Alveoli collapse, deflation, high pitched

Crackle

Bronchiovesicular breath sound origin

Created by air moving through large airways

Vesicular breath sound origin

Created by air moving through smaller airways

Bronchial breath sound origin

Created by air moving through trachea close to chest wall

Define macular degeneration

Damaging sharp and central vision. Wet and dry. Wet blood vessels from under the macula. Dry occurs when the macula thins causing blurring and eventually blindness

Define ulcer

Deep loss of skin surface that extends to dermis and frequently bleeds and scars, varies in size

Dull or thud like sound:

Dense areas like heart and liver; when fluid or solid tissue replaces air containing lungs

What could smelling a fruity, sweet smell be linked to

Diabetes acidosis

What does the D stand for in the skin ABCD assessment

Diameter

Temperature is best assessed using the _________ portion of the hand

Dorsal

Position to assess head, neck, thorax and lungs, breasts, axillae, heart and abdomen, best to assess abdomen

Dorsal Recumbent

Flexion of toes and foot upward

Dorsiflexion

Define nodule

Elevated solid mass, deeper and firmer than papule 1-2 cm

Example of tumor

Epithelioma

E in PERRLA

Equal

Vibration on "99" vocalization is

Equal and stronger at the top

What does CAGE mean?

Ever feel the need to Cut down on your drinking? Do you get Annoyed by people criticizing you? Do you feel Guilty about drinking? Have you ever used a drink as an Eye opener or to make you feel normal?

Turning body part away from midline

Eversion

Pt can't express thoughts, but understand what they want to say

Expressive aphasia

Increasing angle between two bones

Extension

Rotation of join outward

External rotation

Exophthalmos

Eye bulging

Define hyperopia

Farsightedness. Can see distant objects but not close ones

Transports and stores fat soluble vitamjns

Fat

Provide structure for cell membranes and cushioning for internal organs

Fats

What pulse would you check if your pt has a heart cath?

Femoral artery

Define macule

Flat, non-palpable, change in skin color, smaller than 1cm

Decreasing angle between two bones

Flexion

Define health maintenance

Follow up for previously treated condition, or chronic illness

What is the primary purpose of a physical exam?

Health History

When assessing heart, what should you ask first?

Heart health history

What 3 things do you always assess?

Heart, lungs, abdomen

Example of wheal

Hive, mosquito bite

If apical pulse is <60 BPM during certain medication administration, what do you do?

Hold medication

Tympanic sound:

Hollow, drum like, over stomach; indicates excessive air

Movement of body part beyond its normal resting extended position

Hyperextension

Define presbyopia

Impaired near vision at middle age and older adults caused by loss of elasticity of the lens

Define cataracts

Increased capacity of the lens

What does Hypertonicity mean?

Increased resistance with any sudden passive movement of a joint

Culture that doesn't make eye contact and even thinks it is rude

Indian

What is phlebitis?

Inflammation of the vein

Abdomen assessment order

Inspect Auscultation Palpation

I P P A O

Inspect Palpate Percuss Auscultate Olfactory

I P P A O

Inspection Palpation Percussion Auscultation Olfactory

Rotation of joint inward

Internal rotation

Define glaucoma

Intraocular structural damage from elevated intraocular pressure; leads to blindness

Turning body part away from midline

Inversion

Patient culture who wish for no blood to be drawn

Jehovah's witness

Position to assess recctum

Knee-chest

Best place to check for cyanosis?

Lips

Position to assess female genitalia

Lithotomy

What organs are found in the upper right quadrant of the stomach?

Liver and gallbladder

Hyper resonant sound:

Louder, lower pitched than resonant; children chests or thin adults or pneumothoraxic

The bell of the stethoscope is for _______ pitch sounds, so press __________

Low lightly

Resonant sound:

Low pitched, hollow, heard over normal lung tissue

Examples of saturated fats

Meats, lards, butter, cheese, dairy products, palm oil and coconut oil

What valves close to cause S1?

Mitral and Tricuspid

Define annual exams

More comprehensive than focused; mammograms

What is peristalsis?

Movement inside the abdomen

What does atrophy mean?

Muscle decrease

What does Hypotonicity mean?

Muscle feels flabby

Where to look for pallor?

Nails, nail beds, and lips

Define myopia

Near sightedness. Can see close but not distant objects

Maybe be a cancerous cyst if

No pain, no movement

Is tactile fremitus normal or abnormal?

Normal

Examples of monounsaturated fats

Olive oil, canola oil, peanut oil, avocados, peanut butter almonds

What does muscle cast mean?

One muscle much stronger than muscle on opposite side

Flat or extremely dull sound:

Over bone

Where can you best hear bronchial breath sounds?

Over trachea

Vibration is best felt using

Palmar or ulnar surface of the entire hand and the base of the fingers

Define whisper test

Patient should hear you 1-2 feet away

Where can you best hear vesicular breath sounds?

Periphery of lung, except over scapula

Bending of toes and foot downward

Plantar flection

Grating, rub

Pleural friction rub

Where can you best hear bronchovesicular breath sounds?

Posteriorly between scapulae and anteriorly over bronchioles lateral to sternum and first and second ICS

Movement of body part beyond its ventral surface faces downward

Pronation

Position to assess musculoskeletal system, assess hip and knee extension of hip joint

Prone

Makes essential hormones and enzymes

Protein

Needed for growth, development, maintenance, and repair

Protein

P in PERRLA

Pupils

PERRLA

Pupils, Equal, Round, Reactive to Light, Accommodation

How do you check for vascularity?

Push into skin and see if it blanches

Check thumb side of wrist for which pulse

Radial

Second R in PERRLA

Reactive

Pt can't express thought and does not understand

Receptive aphasia

What is erythema?

Redness of the skin

Assessed signs that indicate oxygenation problems

Reduced mental alertness, nasal flaring, somnolence, and cyanosis

Continuous, low pitched

Rhonchi

continuous sounds caused by muscular spasm, fluid, or mucus in larger airways; or new growth or external pressure causing turbulence. Best heard over bronchial tree

Rhonchi are low-pitched

First R in PERRLA

Round

Types of physical exams

Screening Health maintenance Annual exam Focused exam

Define objective date

Signs; what is assessed, labs, tests

Position to assess rectum and vagina

Sims

Position to asses head, neck, back, thorax and lungs, breasts, axillae, heart, vital signs, and upper extremities

Sitting

Largest organ in the body

Skin

How do you test a pt's C7 facial nerve?

Smile, raise eyebrows, wrinkle eyebrows Used for Pt's with a stroke

Define Weber test

Sound heard equally both ears

Examples of polyunsaturated fats

Soybean oil, sunflower oil, walnuts, flaxseed, sunflower seeds, fish

What organs are found in the upper left quadrant of the stomach?

Spleen and pancreas

Rules of palpation

Start with light palpation, be systematic, calm and gentle Proceed to deep palpation if necessary.

Movement of body part so front or ventral surface faces upward

Supination

Position to asses head, neck, thorax and lungs, breasts, axillae, heart, abdomen, pulse sites

Supine

What is Edema?

Swelling

Define subjective data

Symptoms; what the patient says, opinion

What is tactile fremitus?

Tactile fremitus are vibrations that are felt by hand on the chest wall, tested by having pt say "ninety nine"

Common area for cancer in breast

Tail of spence

What do you palpate the skin for?

Temperature Moisture Texture Turgor Tendernes Thickness

The bottom region of the heart is called what?

The apex

If the patient is seriously ill, what do you asses first?

The body system that is most at risk

Define atrophy

Thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size

Check little finger side of wrist for what pulse

Ulnar

Use the bell to hear

Unexpected heart sounds, bruits

Define focused exam

Used for acute illness, more detailed, will ALWAYS include assessment of heart and lungs

superficial veins that become dilated, especially when the legs are in a dependent position

Varicosities

Pumps blood in

Veins

Soft, breezy, and low pitched. Inspiratory phase is 3x longer than exploratory

Vesicular breath sounds

Found in carrots, sweet potatoes, spinach, broccoli, egg yolks

Vitamin A

Helps vision keeping eyes, mouth, skin, & lungs moist

Vitamin A

Deficiency results in night blindness, dry skin/nails, acne, ridges on nails

Vitamins A

High pitched, whistle, continuous, nasal flaring

Wheezes

high-pitched continuous musical sounds or whistling sound like a squeak heard continuously during inspiration or expiration. They usually are louder on expiration and often are heard in asthma. Heard in bronchial tree

Wheezes

How to listen to lungs?

With diaphragm, press firmly

Define ecchymosis

a discoloration of the skin resulting from bleeding underneath, typically causes bruising

Define hematoma

a solid swelling of clotted blood within the tissues; goose egg, blood underneath

Pale color, cool extremities, decreased for absent pulse, thin shiny skin with decreased hair growth and thickened nails are examples of ________ insufficiency

arterial

Fist percussion helps

assess for tenderness over the kidneys, liver and gallbladder

Use the ________ of the stethoscope and listen for low-pitched extra heart sounds such as S3 and S4 gallops, clicks, and rubs.

bell

Lesions are measure in

centimeters

Define vesicles

circumscribed elevation of skin filled with serous fluid, smaller than 1cm

Symptoms that guide your data collection more efficiently

clinical manifestations

Bruits

created by turbulence in major arteries due to blockages of increased vasculature such as enlarged thyroid; carotid artery

Example of a macule

freckle, petechiae

Use the diaphragm to hear

heart sounds, bowel sounds, lung sounds

Example of vesicle

herpes simplex, chickenpox

The diaphragm of the stethoscope is for _______ pitch sounds, so press ________

high firmly

Define wheal

irregularly shaped, elevated area or superficial localized edema, varies in size

Bananas and avocados contain

latex

Auscultation is used to hear

lung, bowel, and heart sounds; + bruits

1st focused assessment:

pain

5 P's

pain, pulse, pallor, paresthesia, paralysis

dry, rubbing or grating quality and is caused by inflamed pleura: parietal pleura rubbing against visceral pleura. High pitched

pleural friction rub

The finger tips are sensitive to

pulsation, position, texture, size and consistency

Define tumor

solid mass that extends deep through subcutaneous tissue, larder than 1-2cm

Brown pigmentation around ankles and edema are examples of __________ insufficiency

venous

Dependent edema around the area of the feet and ankles is a sign of

venous insufficiency or right-sided heart failure`

Example of ulcer

venous stasis ulcer

best heard over the periphery of the lung. They are breezy and low pitched

vesicular breath sounds

Example of a nodule

wart