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