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nursing > 2410wk1&2 (exam 1) > Flashcards

2410wk1&2 (exam 1) Flashcards

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1
Q

what are approaches to assessment

A
  1. cephalocaudal
  2. least to most invasive
  3. validate subjective data (episodic, complaint, injury or discomfort
  4. screening
  5. comparison
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2
Q

planes of the body

A

coronal (anterior posterior
transverse (proximal distal)
sagittal (medial or lateral)

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3
Q

patient positions

A 
standing
sitting
high fowler
semi fowler
recumbant/supine
sims
lithotomy
knee chest
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4
Q

what can fruity/ metallic/offensive breath be indicative of

A

fruity: metabolic disorder accomopanied by acidosis or pseudomonas
metallic: Gi bleed
offensive: poor oral hygiene dental caries bronchitis

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5
Q

describe light palpation and use

A

pressing 1/2 to 3/4 inch check surface characteristics lesions superficial masses muscle tone, tenderness

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6
Q

describe palpation and use

A

press 2in’ identify organs identifies abnormal organs or masses

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7
Q

what info is gathered from percussingq

A

size location
density structure
detects masses elicits pain
deep tendon reflexes

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8
Q

with indirect percussing idenifty hands

A

stationery hand: pleximeter

striking hand: plexor

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9
Q

describe 6 percussion notes

A
  1. softer note: denser structure
  2. resonant: heard over lungs
  3. hyperresonant : heard over child’s lung
  4. tympany: stomach and intestines
  5. dull: heard over spleen
  6. flat: heard over muscle.
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10
Q

define auscultation

A

listening to sounds through use of stethoscope

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11
Q

what is bruits

A

turbulence

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12
Q

what are adventitious sounds and give an example

A

abnormal sounds : such as wheezing

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13
Q

what sounds would you use the diaphragm or belll for when ascultating

A

bell: low pitches
diaphragm: high pitches

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14
Q

what range is norm for temp

A

96.9-99.4

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15
Q

what are age related variables in temp

A

elderly: less likely to develop fever
children: reduced capacity to regulate temp

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16
Q

what is the temp measurement conversion

A

faren: (C x 9/5) +32
Cels: (F-32) x 5/9

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17
Q

when to report temp

A
  1. changed from baseline

2. spikes greater than 101 F

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18
Q

what info does pulse give (4)

A
  1. strength of heart’s contraction
  2. rhythm
  3. volume of blood
  4. patency
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19
Q

give range and cause for bradycardia and tachycardia

A

brady: less than 60 (athletes cardiac meds)
tachy: more than 90-100 (loss of blood decreased O2)

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20
Q

what is sinus arrthmia

A

HR increase and decrease with breathing

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21
Q

variations in infant HR

A

brady: less than 80
tachy: more than 190
kids less than 3 take hr apically

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22
Q

causes of tachy HR

A 
emotions & stress
exercise
fever
anemia
disease (shock hemorrhage hypoxia
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23
Q

causes of brady HR

A

vagal/valsalva response (vomitting or pooping)
medications
hypothermia

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24
Q

what is PMI and where is it found

A

Point of maximum intensity Apical Pulse 5th ICS MCL

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25
Q

what are the five pulse types

A
  1. norm
  2. weak
  3. increased: bounding
  4. pulsus alternans: strong pulse followed by weak pulse
  5. pulsus paradoxus: a regular rhythm of increassed then decreased pulse associated with resp
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26
Q

respirations rates in infants children and adults and ratio

A

infants: 30-40
children: 20-30
adults 10-20
ratio–> 4:1

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27
Q

define eupnea, bradypnea, tachypnea, hypoventil, hyperventil

A

eupnea: normal 12-20
bradypnea: less than 12
tachypnea : more than 20
apnea: absence
hypoventilation: rate and depth decreased
hyperventilation: rate and depth increased

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28
Q

define dyspnea, orthopnea, cheynes stokes, kussmaul

A

dyspnea: SOB
othopnea: difficulty breathing while laying supine
cheynes stokes: alternating apnea hypovent and hypervent
kussmaul: rate and depth increased (seen with dsieases)

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29
Q

3 statement about BP

A

1 gives info on PT cardiovascular & circulatory sys
2 BP stated in term of mmHg
3 measures pressure of blood against arterial wall

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30
Q

define systole and diastole & pulse pressure

A

sys: contrax at its height (max pressure ventricular contrax)
diastole: ventricular relaxn, resting pressure btw contraxn
pp: reflects stroke volume difference between sys and dias (norm 30-50)

31
Q

4 factors that influence bp

A
  1. blood volume: decrease BV decrease BP
    2 axn of <3: increase pump axn increase BP
  2. resistance of vessels: decrease elastic/increase blood viscosity = increase BP
  3. cultural diff: HTN in black ppl
32
Q

NIH BP ranges

A

optimal: less than 120/80
norm: less than 130/85
pre-HTN: 130-139/85-89
stg 1: 140-159/90-99
stg 2: 160-179/100-109
stg 3: greater than 180/110

33
Q

bp cuff dimensions

A

width = 40%
length= 80%
cover 2/3

34
Q

bp sites

A

bicep: brachial
forearm: radial
thigh: popliteal

35
Q

define auscultory gap

A

no sound btw phase 1 & 2, common in HTN, results in false low BP reading

36
Q

where to apply pulsox

A

finger toe earlobe bridge of nose

infants/children: palms soles

37
Q

factors that affect pulsox reading

A 
increase
1 dark skin 
2 moisture
3 finger nail polish
4 acrylic nails
5 jaundice
6 low hemoglobin
 decrease
poor capillary refill/perfusion
38
Q

3 p’s of diabetes

A

polyuria
polyphagia
polydipsia

39
Q 
glucose level ranges
norm
acute
panic
medical fasting
random norm
A

norm:70-106
acute: below 55 or above 400
panic: below 40 above 700
medical fasting: normal should be below 120
random blood glucose: below 200

40
Q

s/s hyperglycemia

A 
warm dry skin
dry mucousal membrane
tachy<3
weak thready pulse
hypotension
3 Ps
41
Q

s/s hypoglycemia

A 
cool and clammy
headache
impaired motor funx
anxiety
hypotension
tachy<3
42
Q

describe structure of skin

A

epidermis: outer layer melanocytes
dermis: supportive layer of connective tissue or collagen, skin appendages
subq tissue: adipose tissue

43
Q

skin developmental factors for infants and children

A
  • more permeable to h2o
  • sebacious glands
  • temp regulation is immature (b/c of less eccrine glands & subq tissue, cannot shiver)
  • pigment system not well developed
44
Q

define:
xerosis
seborrhea
diaphoresis

A

xerosis: excessive dryness of skin
seborrhea: oiliness
diaphoresis: excessive moisture

45
Q

define:
pruritis
alopecia
hirsutism

A

pruritis: itchiness
alopecia: hair loss
hirsutism: excessive hair

46
Q 
causes of:
pallor
erythema
cyanosis
jaundice
A
  • pallor: fear peripheral vasoconstrict. smoking shock anemia
  • erythema: fever, inflamm, polycythemia
  • cyanosis: hypoxia, shock, <3 failure
    jaundice: liver problem (cirrhosis, hep ABC, sickle cell
47
Q

annular lesion
confluent
discrete

A

Annular: circular (ringworm)

confluent: run together (hives)
discrete: distinct, remains separate (pimple)

48
Q

grouped
gyrate
target

A
  • clusters (contact dermatitis)
  • twisted (poison ivy)
  • lesion with in lesion (like bulls eye seen in lyme disease or erythema multiforme)
49
Q

linear

zosteriform

A
  • scratch of streak

- linear along a nerve route (shingles)

50
Q

macule
patch
papule

A
  • flat circumscribed 1cm (cafeaulait spot, vitiligo)

- solid, elevated circumscribe, <1cm (wart)

51
Q

plaque
nodule
tumor

A
  • coalesced papules that form an elevation >1cm (psoriasis)
  • solid, elevated, hard/soft >1cm deeper in dermis (fibroma)
  • > 2cm firm/soft (lipoma)
52
Q

wheal
uriticaria
vesicles

A
  • superficial, raised, transient, erthematous,2ndary to edema (hive)
  • hives, coalesced wheals, intensely pruritic
  • elevated lesion containing fluid < 1cm (herpes)
53
Q

bulla
cyst
pustule:

A
  • > 1cm elevated fluid filled cavity(burn blister)
  • encapsulated fluid filled cavity in dermis or subq layer (sebacious cyst, ganglion)
  • <1cm turbid fluid (pus) filled cavity (acne)
54
Q

crust
scale
fissure
erosion

A
  • thickened dried exudate when vessicle/pustule burst
  • flakes of skin, excess keratin (psoriasis, eczema)
  • linear crack, extending to dermis (athlete’s foot)
  • shallow scooped out depression, superficial dermis loss (Stg II DPU)
55
Q

ulcer
excoriation:
lichenification

A
  • deeper depression, extending to dermis (stg III DPU)
  • superficial self inflicted scratch
  • thickening of skin, happens with prolonged scratching or rubbing
56
Q

difference b/w primary vs secondary lesion

A

primary lesion: is the first appearance

secondary : altered state of primary lesion

57
Q

(Vascularity and Bruising)
angioma
telangiectasis
echymosis:

A
  • 1-5mm smooth, slightly raised bright red, blanchable (develop on trunk common with aging)
  • [ Tell Angie Hector’s Sis] blanchable fiery red star shaped lesion on face neck chest, seen with liver disease pregnancy estrogen therapy
  • bruising
58
Q

(Hemangiomas)
portwine stain
strawberry mark

A
  • benign proliferation of blood vessels, flat macular patch covering scalp or face along CN V, at birth, color deepens with exertion, stress
  • macular plaque covering scalp or face, raised red, immature capillaries, at birth but resolves by 5-7 y.o.
59
Q

ABCDE danger signs of lesions

A 
Asymmetry
Border irregularity
Color variation
Diameter >6mm pencil eraser
Elevation/enlargement
60
Q

malignant melanoma

cause, at risk, ratio of occurence

A

UV exposure, blued-eyed blondes or gingers

61
Q

basal cell carcinoma 5 characteristics

A
  • most common
  • least malignant
  • 2ndary to UV exposure
  • non healing sores
  • nodular, on head hands and back
62
Q

Describe 2 skin lesions seen in aging population

A
  1. seborrheic keratosis-crusty raised thickened areas of pigmentation on trunk, face, and hands
  2. acrochordons- skin tags
63
Q

petechiae

purpura

A
  • nonblancable tiny red, purple, brown macules caused by bleeding from superficial capillaries, this is associated with low platelets
  • extravasation or bleeding into tissues
64
Q

mobility/turgor test site
cause of decreased turgor
define tenting

A
  • anterior chest under clavicle (children abdom.)
  • edema or dehydration
  • poor turgor, tissue will stand by itself (indicative of dehydration)
65
Q 
tinea capitis
alopecia areata
trichotillomania
pediculosis capitis
furuncle
A
  • ringworm on scalp
  • round patch of hair loss
  • self inflicted hair loss
  • lice
  • infected hair follicle
66
Q

what is the schamroth technique, what does abnorm finding indicate

A

examining nailbase 160 degrees or less, increased angle seen in chronic hypoxia (clubbing) or cardiac or resp. dz

67
Q

what does sluggish return indicate when pressing nailbed, time of norm return

A

problems with periph. circulation, 3 sec. norm

68
Q 
koilonychia
beau's lines
paronychia
onycholysis
onychodystrophy
A
  • spoon nail
  • transverse (horizontal) groove
  • inflamm of nail folds
  • loosening of nail bed
  • thickening of toe nail
69
Q

what causes DPU

A

Decubitus Pressure Ulcer- localized ischemia (decreased blood supply) subsequent tissue necrosis

70
Q

etiology of DPU (6 statements)

A
  1. pressure to tissue b/w bed and bony prominence
  2. ischemia
  3. after pressure –> area of pale skin
  4. removal of pressure –> skin bright red (reactive hyperemia)
  5. disappearance of redness –>no perm. damage
  6. persistent redness –> damage to tissue
71
Q

when does shearing happen commonly

what is maceration

A
  • fowler’s position, body sliding with pressure of PT’s body weight
  • softening of tissue (incontinence)
72
Q

DPU risk factor associated with body temp

A

excessive body heat causes increased BMR, cells have increase need for o2

73
Q

describe 4 stages of DPU

A

I. non blanchable erythema
II. partial thickness skin loss: abrassion blister shallow crater involves epidermis & possibly dermis
III. full thickness skin loss, necrosis to subq tissue may extend to fascia bu not through it
IV. full thickness skin loss, necrosis damage to muscle, bone or supporting structure

74
Q

6 subscales from braden scale assessment
possible points
score that indicates at risk for DPU
how often charted

A
  1. sensory perception
  2. moisture
  3. activity
  4. mobility
  5. nutrition
  6. friction/shear
    -23
    <18
    Q 48hrs.

nursing (15 decks)

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