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Health Assessment (NUR 202) > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Ch. 19

List the 4 anterior thoracic landmarks

A
  • Suprasternal notch: hollow U-shaped depression just above the sternum, between the clavicles
  • Sternum
  • Manubriosternal angle: lines up with the second rib
  • Costal angle: R & L costal margins form an angle (usually 90° or less) where they meet at the xiphoid process
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2
Q

Ch. 19

What is the Manubriosternal Angle?

A
  • angle of Louis
  • in line / lines up with 2nd rib
  • useful place to start counting ribs
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3
Q

Ch 19

What are the 4 Posterior Thoracic Landmarks?

A
  • Vertebra prominens: most prominent bony spur protruding at the base of the neck when you flex your head
  • Spinous processes: align with their same numbered ribs only down to T4. after T4, the spinous processes angle downward from their vertebral body & overlie the vertebral body & rib below
  • Inferior border of scapula: usually located at the 7th or 8th rib
  • Twelfth rib
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4
Q

Ch 19

What is unique about the spinous processes landmark?

A
  • align with their same numbered ribs only down to T4
  • After T4 the spinous processes angle downward from their vertebral bodies & overlie the vertebral body & rib below
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5
Q

Ch 19

What are the important reference lines to keep in mind when assessing the thorax & lungs?

A
  • Midsternal
  • Midclavicular
  • Scapular
  • Vertebral
  • Anterior, Posterior, & Midaxillary lines
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6
Q

Ch 19

What is the mediastinum?

A
  • middle section of the thoracic cavity
  • contains the esophagus, trachea, heart, & great vessels
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7
Q

List the lobes of the lung

Ch 19

A
  • RUL, RML, RLL
  • LUL & LLL
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8
Q

When are accessory muscle used & where are they located?

Ch 19

A
  • used when someone has difficulty breathing

Location: found in the intercostal spaces (also includes sternomastoid muscles & abdominal muscles)

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9
Q

What does White or Clear Sputum indicate?

Ch 19

A
  • cold
  • viral infection
  • bronchitis
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10
Q

What does Yellow or Green Sputum indicate?

Ch 19

A

Bacterial infection

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11
Q

What does Rust-Colored Sputum indicate?

Ch 19

A
  • TB
  • Pneumococcal pneumonia
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12
Q

What does Pink, Frothy sputum indicate?

Ch 19

A
  • pulmonary edema
  • certain sympathomimetic medications
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13
Q

What is orthopnea?

Ch 19

A

difficulty breathing when laying down

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14
Q

Explain the Anteroposterior / Transverse Diameter

Ch 19

A

The transverse measurement should be twice as long as anteroposterior measurement

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15
Q

What should the Anteroposterior / Transverse diameter be?

Ch 19

A

1:2

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16
Q

Where should the thumbs be placed when evaluating for symmetric expasion?

Ch 19

A

place thumbs at ribs 9 or 10

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17
Q

In what conditions does tactile fremitus increase & decrease?

Ch 19

A
  • Increase: pneumonia
  • Decrease: COPD, asthma, PE, collapsed lung (pneumothroax), emphysema
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18
Q

What sounds will you hear when listening over the scapula, organs, above the shoulders, and intercostal spaces?

Ch 19

A
  • Scapula: flat
  • Organs: dull
  • Above Shoulders & Intercostal Spaces: resonance
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19
Q

What is the predominant sound heard when listening to lung sounds?

Ch 19

A

vesicular breath sounds

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20
Q

What are 3 types of breath sounds to listen for during auscultation?

Ch 19

A
  • Bronchial
  • Broncovesicular
  • Vesicular
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21
Q

List types of adventitious sounds & describe them

Ch 19

A
  • Crackles: discontinuous popping heard during inspiration
  • Wheezes: continuous musical sound heard mainly on expansion
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22
Q

Where are bronchial sounds heard anteriorly & when are they longest?

Ch 19

A

heard over the trachea & are longest on expiration

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23
Q

What are Cheyne-Stokes Respirations & when are they heard?

Ch 19

A

a cycle when respirations wax & wane in a regular pattern (periods last 30 - 45 seconds with perods fo apnea alternating the cycle)

  • Heard / Common With: head trauma, brain abscess, heat stroke, meningitis, & encephalitis
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24
Q

What is a stridor?

Ch 19

A

high pitched inspiratory crowing sound heard due to upper airway obstruction

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25
Q

Tactile fremitus findings would be increased when

a.) The patient has a mild case of pneumonia

b.) The patient has an advanced case of pneumonia

c.) The patient has a pleural effusion

d.) The patient has a blocked bronchus

Ch 19

A

b.) The patient has an advanced case of pneumonia

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26
Q

Which of the following is a true statement regarding the findings related to percussion?

a.) Percussion is a useful technique for identifying small lesions in lung tissue.

b.) Percussion is helpful only in identifying surface alterations of lung tissue.

c.) Percussion notes are not influenced by the overlying chest muscle & fat tissue.

d.) A dull not elicited with percussion is the expected finding.

Ch 19

A

b.) Percussion is helpful only in identifying surface alterations of lung tissue

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27
Q

Which of the following correctly expresses the relationship to the lobes of the lungs & their anatomic position?

a.) Upper lobes – lateral chest
b.) Upper lobes – posterior chest
c.) Lower lobes – posterior chest
d.) Lower lobes – anterior chest

Ch 19

A

c.) Lower Lobes – posterior chest

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28
Q

What organs are considered solid viscera?

Ch 22

A
  • Spleen
  • Adrenal glands
  • Liver
  • Pancreas
  • Ovaries
  • Uterus
  • Kidneys
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29
Q

What organs are considered hollow viscera?

Ch 22

A
  • Bladder
  • Colon
  • Gallbladder
  • Stomach
  • Small intestine
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30
Q

What is the difference in solid & hollow viscera?

Ch 22

A

The shape of hollow viscera can change

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31
Q

What order do you perform an abdomen exam?

Ch 22

A
  • Inspection
  • Auscultation
  • Percussion
  • Palpation
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32
Q

What arteries are listened to int he abdomen & where are they heard?

Ch 22

A
  • Aorta: midline (epigastric region)
  • Renal: above the umbilicus (RUQ & LUQ)
  • Iliac: below the umbilicus (RLQ & LLQ)
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33
Q

List which organs are found in each of the quadrants of the stomach

Ch 22

A
  • RUQ: Liver & Gallbladder
  • RLQ: Ascending colon, cecum, appendix, bladder
  • LUQ: Spleen, stomach, small intestine
  • LLQ: Descending colon, sigmoid colon
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34
Q

What is dysphagia?

Ch 22

A

difficulty swallowoing

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35
Q

What is dysphasia?

Ch 22

A

Difficulty speaking

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36
Q

What factors are important to keep in mind when performing an abdominal assessment on aging adults?

Ch 22

A
  • increased fat accumulation
  • abdominal muscles relax
  • decreased saliva, sense of tase (increased use of salt & sugar)
  • Delayed esophageal emptying (increases risk of aspiration)
  • Decreased gastric acid secretion
  • Increased incidence of gallstones
  • Liver size decreases after age 80
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37
Q

What can striae indicate?

Ch 22

A

ascites

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38
Q

What is ascites?

Ch 22

A

fluid accumulation in the abdomen

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39
Q

What are 4 types of contour used to describe the abdomen?

Ch 22

A
  • flat
  • rounded
  • scaphoid (concave)
  • protuberant
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40
Q

What do normal bowel sounds sound like & what is the normal range?

Ch 22

A
  • high pitched, gurgling, cascading
  • irregular, 5-30 per minute
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41
Q

How many sounds per minute is the range for hypoactive bowel sounds

Ch 22

A

< 5 per minute

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42
Q

How many sounds per minute is the range for hyperactive bowel sound?

Ch 22

A

> 30 per minute

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43
Q

What must you do to determine that bowel sounds are absent?

Ch 22

A

Listen to each abdominal quadrant for 5 minutes

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44
Q

Which side of the stethoscope is used to auscultate for vascular sounds on an abdominal exam?

Ch 22

A

BELL

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45
Q

What is a bruit?

Ch 22

A

abnormal vascular sound caused by stenosis of an artery that results in turbulent blood flow (whooshing sound)

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46
Q

What is the predominant sound produced when percussing the abdomen?

Ch 22

A

tympany

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47
Q

What sounds can be expected over organs & bones when percussing?

Ch 22

A

Organs: dull sound

Bones: flat sound

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48
Q

What tests are used to test for ascites?

Ch 22

A
  • Fluid wave
  • Shifting dullness
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49
Q

What does a positive Blumberg’s sign indicate / what is Blumberg’s sign used to test for?

Ch 22

A

appendicitis

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50
Q

What is Murphy’s sign used to test for?

Ch 22

A

inflamed gallbladder

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51
Q

What can costovertebral (CVA) tenderness indicate?

Ch 22

A

Kidney stones / Kidney infection

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52
Q

List 3 types of hernias

Ch 22

A
  • Umbilical Hernia
  • Epigastric hernia: above umbilicus
  • Incisional Hernia: anywhere there’s an incision
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53
Q

What is another name for Blumberg’s Sign?

Ch 22

A

rebound tenderness

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54
Q

When the patient reports that a certain spot in the abdomen is tender, it is best to…

a.) Palpate that spot last to prevent pain from interfering with the rest of the examination

b.) Palpate that spot first to avoid prolonging the patient’s anticipation

c.) Avoid the spot entirely as other clinicians are going to palpate it after you

d.) Palpate in the same order you always would to avoid missing something because you broke your routine

A

a.) Palpate that spot last to prevent pain from interfering with the rest of the examination

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55
Q

Which of the following is not in the list of common causes for abdominal distention?

a.) Flatus
b.) Fetus
c.) Fluid
d.) Follicles
e.) Fat

Ch 22

A

d.) Follicles

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56
Q

Which of the following are are true? (select all that apply)

a.) Listen for bowel sounds in each quadrant

b.) Always auscultate before palpating as palpation may alter bowel sounds

c.) Use the bell of the stethoscope to auscultate for bowel sounds

d.) Listen for at least 5 minutes before documenting that bowel sounds are absent

Ch 22

A

a.) Listen for bowel sounds in each quadrant

b.) Always auscultate before palpating as palpation may alter bowel sounds

d.) Listen for at least 5 minutes before documenting that bowel sounds are absent

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57
Q

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is…

a.) Diarrhea
b.) Peritonitis
c.) Laxative use
d.) Gastroenteritis

Ch 22

A

b.) Peritonitis

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58
Q

When examining a patient with good muscle wall relaxation the nurse observes abdominal pulsations between the xiphoid & umbilicus. The nurse would suspect that these are…

a.) Pulsations of the renal arteries
b.) Pulsations of the interior vena cava
c.) Normal abdominal aortic pulsations
d.) Increased peristalsis from a bowel obstruction

Ch 22

A

c.) Normal abdominal aortic pulsations

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59
Q

Which artery is the main blood supply in the arms?

Ch 21

A

Brachial artery

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60
Q

Which artery is the main blood supply for the legs?

Ch 21

A

Femoral artery

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61
Q

What are the 4 key lymph nodes Professor Bell emphasized & what do they drain?

Ch 21

A
  • Cervical: head & neck
  • Axillary: arms & breasts
  • Epitrochlear: hands
  • Inguinal: groin & lower extremities
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62
Q

What is arteriosclerosis?

Ch 21

A

peripheral blood flow grows more rigid with age

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63
Q

What is atherosclerosis?

Ch 21

A

fatty plaque build up inside of the arteries

64
Q

What is intermittent claudication?

Ch 21

A

cramping pain in the calves (or another specific muscle group) induced by exercise / walking & caused by obstruction of the arteries

65
Q

What can the use of a doppler ultrasonic stethoscope confirm?

Ch 21

A

low or no pulse

66
Q

Where are epitrochlear lymph nodes located?

Ch 21

A

Anticubital region

67
Q

What is the modified Allen test used to screen for?

Ch 21

A

carpal tunnel & PVD

68
Q

Where is teh doralis pedis pulse located?

Ch 21

A

extender toe on top of the foot

69
Q

Where is the posterior tibial pulse located?

Ch 21

A

inside the ankle, near the ankel bone

70
Q
  • What does the Ankle-brachial index (ABI) do?
  • What can it indicate?
  • What is the normal value?

Ch 21

A
  • checks BP in lower extremties compared to BP in the arm (ankle systolic pressure / arm systolic pressure)
  • Indicates: PVD
    • Normal: 1.06 or 106%
71
Q

What are the different variations in arterial pulse?

Ch 21

A
  • 1+: weak, “thready” pulse
  • 2+: NORMAL
  • 3+: full, bounding pulse
72
Q

The relevant variable when discussing claudication with a patient is:

a.) Related foods
b.) Distance
c.) Blood glucose
d.) Emotional state

Ch 21

A

b.) Distance

73
Q

Where is the APEX of the heart located?

Ch 20

A

5th intercostal space at the midclavicular line

74
Q

Where are S1 and S2 heard the loudest?

Ch 20

A
  • S1 loudest at APEX
  • S2 loudest at BASE
75
Q

Explain the path of blood flow through the heart

Ch 20

A

RIGHT
1.) SVC/IVC
2.) Right Atrium (RA)
3.) Tricuspid Valve (TV)
4.) Right Ventricle (RV)
5.) Pulmonary Valve (PV)
6.) Pulmonary Artery (PA)

LEFT
1.) Pulmonary Veins (PV)
2.) Left Atrium (LA)
3.) Mitral Valve (MV)
4.) Left Ventricle (LV)
5.) Aortic Valve (AV)
6.) Aorta

76
Q

What causes the first heart sound (S1)?

Ch 20

A

Closure of the AV valve

  • Tricuspid
  • Mitral
77
Q

What causes the second heart sound (S2)?

Ch 20

A

closure of the semilunar valve

  • Pulmonic
  • Aortic
78
Q

When would a third heart sound be heard (S3)?

Ch 20

A

AFTER S2 (early diastole)

79
Q

What conditions can cause a third heart sound (S3)?

Ch 20

A
  • CHF
  • acute MI
  • late pregnancy
  • elderly patient with CAD
  • young children
80
Q

When would a fourth heart sound be heard (S4)?

Ch 20

A

BEFORE S1 (late diastole)

81
Q

What groups of people can have & what conditions can cause a fourth heart sound (S4)?

Ch 20

A
  • atheletes
  • elderly
  • chronic HTN
  • aortic stenosis
  • cardiomyopathy
82
Q

What do jugular veins give us information about?

Ch 20

A

RIGHT sided heart pressure

83
Q

JVD shows more in which jugular veins & what can JVD indicate?

Ch 20

A
  • Shows more in the R jugular vein
  • JVD can indicate HF
84
Q

What is dyspnea?

Ch 20

A

difficulty breathing

85
Q

What is orthopnea?

Ch 20

A

difficulty breathing while lying flat

86
Q

What is fatigue related to regarding the cardiovascular system?

Ch 20

A

related to cardiac output

87
Q

What can cyanosis or pallor indicate regarding the cardiovascular system?

Ch 20

A

decreased cardiac output

88
Q

What side of the stethoscope is used to auscultate carotid arteries / listen for bruit?

Ch 20

A

bell

89
Q

JVD is most obvious when a patient is in what position?

Ch 20

A

supine (lying flat)

90
Q

Where is the apical pulse located?

Ch 20

A

5th intercostal space at the midclavicular line

91
Q

What is the most common irregular heart rhythm?

Ch 20

A

A Fib

92
Q

How long should the apical pulse be listened to?

Ch 20

A

1 minute

93
Q

How is the pulse deficit calculated?

Ch 20

A

(Apical Pulse) – (Radial Pulse)

94
Q

Which side of the stethoscope should be used when listening to the 5 ausculatory areas of the heart?

Ch 20

A

DIAPHRAGM

95
Q

What are the 5 ausculatory areas of the heart?

Ch 20

A

1.) Aortic area

2.) Pulmonic area

3.) Erb’s point

4.) Triscuspid area

5.) Mitral area

APE To Man

96
Q

Where is the aortic area (1) found?

Ch 20

A

2nd intercostal space at the R sternal border

97
Q

Where is the pulmonic area (2) located?

Ch 20

A

2nd intercostal space (L side)

98
Q

Where is Erb’s point (3) located?

Ch 20

A

3rd intercostal space (L side)

99
Q

Where is the Tricuspid area (4) located?

Ch 20

A

5th intercostal space (slightly L of midline)

100
Q

Where is the Mitral area (5) located?

Ch 20

A

5th intercostal space at the midclavicular line

101
Q

What do murmurs sound like?

Ch 20

A

swishing sound

102
Q

Which side of the stethoscope should be used to listen for S3 & S4? How should the patient be positioned when listening for S3 & S4?

Ch 20

A
  • listen with the bell
  • Place the patient in a L lateral position
103
Q

What is a thrill?

Ch 20

A

vibration you can feel (usually at the base)

104
Q

True or False: it is important to document the heart sounds in precisely the correct locations to accurately correlate those sounds with particular valves.

Ch 20

A

False

105
Q

The first heart sound is produced by:

a.) closure of the semilunar valves

b.) closure of the AV valves

c.) opening of the semilunar valves

d.) opening of the AV valves

Ch 20

A

b.) closure of the AV valves

106
Q

Which of the following is an appropriate position to have the patient assume when auscultating the heart sounds?

a.) Roll toward the left side
b.) Roll toward the right side
c.) Trendelenburg’s position
d.) Recumbent position

Ch 20

A

d.) Recumbent position

107
Q

A bruit heard while auscultating the carotid artery of a 65-year-old woman is caused by which of the following?

a.) Decreased velocity of blood flow through the carotid artery

b.) Turbulent blood flow through the carotid artery

c.) Rapid blodo flow through the carotid artery

d.) Increased viscosity of blood

Ch 20

A

b.) Turbulent blood flow through the carotid artery

108
Q

Which salivary glands are accessible to examen (NOT palpable)?

Ch 14

A
  • Parotid (in cheeks)
  • Submandibular (beneath mandible)
  • Sublingual
109
Q

What is a goiter?

Ch 14

A

enlarged thyroid gland

110
Q

What is the isthmus

Ch 14

A

middle of the thyroid

111
Q

What lymph nodes are accessible for inspection & palpation?

Ch 14

A
  • Cervical
  • Epitrochlear
  • Axillary
  • Inguinal
112
Q

What is the size of a normal lymph node?

Ch 14

A

less than or equal to 1 cm

113
Q

What are the lymph nodes we’re responsible for in lab?

Ch 14

A

1.) Preauricular
2.) Posterior Auricular (mastoid)
3.) Occipital
4.) Jugulodigastric
5.) Submental
6.) Submandibular
7.) Superifical Cervical
8.) Deep Cervical
9.) Posterior Cervical
10.) Supraclavicular

114
Q

You should be concerned for malignancy or cancer when lymph nodes are…

Ch 14

A
  • fixed
  • hard
  • non-tender
115
Q

Normal lymph nodes should be…

Ch 14

A
  • freely movable
  • < 1 cm
116
Q

What can enlarged or inflammed lymph nodes indicate?

Ch 14

A

acute infection or illness

117
Q

Which of the following is the most appropriate health history question?

a.) Any unusually frequent or unusually severe headaches?

b.) Have you had headaches recently?

c.) Have you ever had a headache?

d.) When di dyour headaches start?

Ch 14

A

a.) Any unusually frequent or unusually severe headaches?

118
Q

Which of the following is the most appropriate health history question?

a.) Any unusually frequent or unusually severe headaches?

b.) Have you had headaches recently?

c.) Have you ever had a headache?

d.) When di dyour headaches start?

Ch 14

A

a.) Any unusually frequent or unusually severe headaches?

119
Q

What are the characteristics of a tension headache?

Ch 14

A
  • Location: bilateral; across frontal, temporal, and/or occipital region (forehead, sides, back of head)
  • Character:bandlike tightness, non-throbbing, non-pulsating
  • Duration:gradual onset; lasts 30 minutes to days
  • Quantity & severity: Diffuse, dull aching pain; mild - moderate pain
  • Aggravating Symptoms or Triggers: stress, anxiety, depression, poor posture; NOT worsened by physical activity
120
Q

What is the definition of a tension headache?

Ch 14

A
  • headache of muskuloskeletal origin
  • mild - moderate pain
  • less disabling form of migraine
121
Q

Describe the characteristics of a cluster headache

Ch 14

A
  • Location: always 1 sided; often behind or around the eyes, temple, forehead, cheeks
  • Character: continuous, burning, piercing, excrutiating
  • Duration: abrupt onset, peaks in minutes, lasts 45 - 90 minutes
  • Quantity & severity: can occur multiple times a day; in “clusters” lasting weeks; severe, stabbing pain
  • Timing: 1-2 / day each lasting 1/2 to 2 hour for 1 - 2 months; then remission for months or years
  • Aggrevating symptoms or triggers: exacerbated by EtOH, stress, daytime napping, wind or heat exposure
122
Q

What is the definition of a cluster headache?

Ch 14

A
  • rare intermittent headache
  • excrutiating
  • unilateral with autonomic signs
123
Q

What are the characteristics of a migraine headache?

Ch 14

A
  • Location: Commonly 1 sided, but may occur on both sides; pain is often behidn the eyes, the temples, or forehead
  • Character: throbbing, pulsating
  • Duration: rapid onset, peaks 1-2 hours, lasts 4 - 72 hours, sometimes longer
  • Quantity & severity: moderate to severe pain
  • Timing: ~ 2 per month, last 1-3 days (~ 1 in 10 patients have weekly headaches)
  • Aggrevating symptoms or triggers: hormonal fluctuations (premenstrual); foods (EtOH, caffeine, MSG, nitrates, chocolate, cheese); Hunger; Letdown after stress; Sleep deprivation; sensory stimuli (flashing lights, perfumes, etc.); changes in weather; physical activity
124
Q

What is the definition of a migraine headache?

Ch 14

A
  • headache of genetically transmitted vascular & trigeminal nerve origin
  • Headache + prodrome, aura, & other symptoms
  • 2 - 3 times as common in women as in men
125
Q

What are the 3 types of headaches & what are the major differences?

Ch 14

A

Tension:
* musculoskeletal origin
* bandlike tightness
* usually occurs bilaterally
* gradual onset
* mild to moderate pain (diffuse, dull aching)

Migraine:
* genetically transmitted vascular & trigeminal nerve origin
* commonly 1-sided, can occur on both sides
* pain often behind eyes, forehead, or temples
* throbbing, pulsating pain
* rapid onset
* moderate to severe pain

Cluster:
* rare, intermittent headache
* unilateral
* continuous, burning, piercing, excrutiating
* abrupt onset
* severe, stabbing pain

126
Q

What is the definition of a migraine headache?

Ch 14

A
  • headache of genetically transmitted vascular & trigeminal nerve origin
  • Headache + prodrome, aura, & other symptoms
  • 2 - 3 times as common in women as in men
127
Q

Which of the following is a true statement regarding the findings related to percussion?

a.) useful techniques for identifying small lesions in lung tissue

b.) notes are not influenced by overlaying chest muscle and fat tissue

c.) helpful only in identifying surface alterations of lung tissue

d.)a dull note elicited with percussion is the expected finding

A

c.) helpful only in identifying surface alterations of lung tissue

128
Q

What is a common side effect of dysphagia?

a.) lack of nutrition
b.) high blood pressure
c.) orthostatic hypotension
d.) abdominal pain

A

a.) lack of nutrition

129
Q

What percentage of carotid stensosis will get surgical intervention?

a.) 5 - 10%
b.) 20 - 30%
c.) 30 - 40%
d.) 50 - 60%

A

d.) 50 - 60%

130
Q

What can cause an increase in tactile fremitus?

A

liquid in the lungs from pneumonia

131
Q

What conditions would NOT increase tactile fremitus?

A
  • asthma
  • emphysema
  • pneumothorax
132
Q

Do veins or arteries have a pulse wave & high pressures?

A

ARTERIES have pulse wave & high pressures

133
Q

Which lymph nodes supply the upper arm, lower arm, & hand?

A

epitrochlear lymph nodes

134
Q

What is a palpable impulse that can be felt by the left lower sternal border?

A

heave / lift

135
Q

What is the main difference between a thrill & a heave/lift?

A
  • You can see & feel a heave / lift
  • You can hear a thrill
136
Q

What causes crackles and where are they heard most often?

A
  • caused by liquid
  • heard in the bases
137
Q

What causes a stridor?

A

restricted airways

harder to breath causes an INCREASE in sounds

138
Q

What is the difference in arterial sclerosis & atherosclerosis?

A
  • Arterial Sclerosis = tightening of BP (systolic & diastolic numbers are closer together)
  • Atherosclerosis = fatty build up in vessels
139
Q

A patient in anaphylaxis may present with which adventitious lung sound?

a.) Crackles
b.) Stridor
c.) Clear Lung Sounds
d.) Pleural Rub

A

b.) stridor

140
Q

Describe chronic arterial symptoms (PAD)

Ch 21

A
  • Location: deep muscle pain (usually calf, but may be lower leg or dorsum of foot)
  • Character: intermittent claudication (feels like “cramp”, “numbness & tingling”, “feeling of cold”)
  • Onset & Duration: chronic pain, gradual onset after exertion
  • Aggrevating Factors: activity & elevation
  • Releiving Factors: rest, dangling
  • Associated Symptoms: low ankle-brachial index; cool, pale skin; diminished pulses; pallor on elevation
  • Those at risk: older & middle-aged adults, African Americans, individuals who smoke, have HTN, DM, obesity, vascular disease, hypercholesterolemia
141
Q

Describe the characteristics of acute arterial symptoms

Ch 21

A
  • Location: varies (distal to occlusion, may involve entire leg)
  • Character: throbbing
  • Onset & Duration: sudden onset (within 1 hour)
  • Associated Symptoms: Pain, Pallor, Pulseness, Paresthesia, Poikilothermia (coldness), Paralysis (indicates severe)
  • Those at risk: history of vascular surgery, arterial invasive procedure, abdominal aneurysm (emboli), trauma, chronic A-Fib
142
Q

What are the main differences in chronic & acute arterial symptoms?

Ch 21

A

CHRONIC
* deep muscle pain
* intermittent claudication
* chronic pain, gradual onset after exertion
* aggravated by activity & elevation
* releived by rest & dangling

ACUTE
* distal to occlusion (may involve entire leg)
* throbbing
* sudden onset

143
Q

What are the characteristics of Chronic Venous Symptoms?

Ch 21

A
  • Location: calf, lower leg
  • Character: aching, tiredness, feeling of fullness
  • Onset & Duration: chronic pain, increases at end of day
  • Aggrevating Factors: prolonged standing, sitting
  • Releiving Factors: elevation, lying, walking
  • Associated Symptoms: edema, varicosities, weeping ulcers at ankles
  • Those at risk: anyone with job involving prolonged standing or sitting, obesity, multiple pregnancies, prolonged bed rest; Hx of HF, varicosities, or thrombophlebitis; veins crushed by trauma or surgery
144
Q

What are the characteristics of Acute Venous Symptoms?

Ch 21

A
  • Location: calf
  • Character: moderate to intense, sharp; deep muscle tender to touch
  • Onset & Duration: sudden onset (within 1 hour)
  • Aggrevating Factors: pain may increase with palpation
  • Releiving Factors: Pain medication
  • Associated Symptoms: Red, warm, swollen legs
145
Q

What are the main differences in Chronic & Acute Venous Symptoms / Disease

Ch 21

A

CHRONIC
* calf, lower leg
* aching, tiredness, feeling of fullness
* chronic pain, worse at end of day
* aggrevated by prolonged standing & sitting
* releived by elevation, walking, lying
* Associated Sx: edema, varicosities, weeping ulcers at ankles

ACUTE
* calf
* moderate to intense, sharp, deep muscle tender to touch
* sudden onset
* pain may increase with palpation
* releived with pain medication
* Associated Sx: red, warm, swollen

146
Q

What signs & symptoms do arterial diseases cause?

Ch 21

A

oxygen deficit

147
Q

What signs & symptoms do venous diseases cause?

Ch 21

A

metabolic waste buildup

148
Q

Venous diseases cause signs & symptoms of ……….

Arterial diseases cause signs & symptoms of …………

Ch 21

A

Venous Dx = s&s of metabolic waste buildup

Arterial Dx = s&s of oxygen deficit

149
Q

Explain the Modified Allen Test?

A

you occlude both radial & ulnar pulses then release the ulnar pulse

150
Q

Explain the Manual Compression Test

A

1.) compress the vein

2.) feel for a wave

**Wave = ** incompetent veins

No Wave = competent veins

151
Q

What does the Manual Compression Test evaluate?

A

Assesses Vein Competence

152
Q

What does the Modified Allen Test evaluate?

A

Assesses overall blood flow in the hands

153
Q

What is hemoptosis?

A

coughing up blood

154
Q

What is deep vein thrombosis (DVT)?

A
  • blocked venous return
  • cyanosis
  • edema
  • inflammation
  • sudden onset
  • intense sharp muscle pain
155
Q

Which peripheral vascular disease is moderate to intense deep muscle pain with palpation & resolved with medication?

a.) Chronic Arterial
b.) Acute Arterial
c.) Chronic Venous
d.) Acute Venous

A

d.) acute venous

156
Q

Where would you find bronchiovesicular sounds?

a.) anterior throat
b.) posterior near the upper spine
c.) lateral chest
d.) posterior beneath scapula

A

b.) posterior near the upper spine

157
Q

Which peripheral vascular disease is a chronic pain, releived by walking, aggravated by prolonged sitting or standing?

a.) Chronic arterial
b.) Acute arterial
c.) Chronic venous
d.) Acute venous

A

c.)Chronic Venous

Health Assessment (NUR 202) (4 decks)

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