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NUR3120 HEALTH ASSESSMENT > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Chronic Obstructive Breathing

A

Shortness of breath due to inability to fully exhale air

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2
Q

Measure Edema

A
  • Scale is subjective
  • 1+ = mild pitting, slight indentation w/ no perceptible swelling
  • 2+ = moderate pitting & indentation subsides rapidly
  • 3+ = deep pitting, indention remains for short time, limb appears swollen
  • 4+ = very deep pitting, indention persists for long time, limb very swollen
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3
Q

Expected Findings for Head, Neck, & Face

A
  • Head should be midline & centered
  • Bruit over thyroid gland & carotids
  • Lymph nodes movable, discrete, soft, & nontender
  • Trachea straight & midline
  • Thyroid usually nonpalpable
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4
Q

Hyperventilation

A

Rapid, deep breathing

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5
Q

Properties of Veins

A
  • Thin-walled, elastic
  • Carry deoxygenated blood to heart
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6
Q

Cheyne-Stokes Respiration

A

A period of fast, shallow breathing followed by slow, heavier breathing and moments without breathing at all

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7
Q

How Does Diastole Occur

A

Heart muscle relaxes, fill with blood

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8
Q

S2

A
  • Short, high-pitched
  • Loudest at base
  • Closure of semilunar valves (pulm & aortic)
  • End of systole (dub)
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9
Q

Risk Factors for Breast Disease (nonmodifiable)

A
  • 2+ 1st degree relatives
  • Previous breast irradiation
  • Menstruation before 12
  • Menopause after 55
  • History: endometrial, ovarain, or colon CA
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10
Q

Low Pitched Wheeze

A
  • Low pitched
  • Monophonic, single note
  • More prominent on expiration
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11
Q

Abnormal Findings of Breast Exam

A
  • Sudden increase in size
  • Redness, bulging, dimpling, lesions, incrd pigmentation, heat, unilateral/dilated superficial veins, edema
  • “orange-peel”
  • Lymphatic drainage
  • Discharge
  • New nipple retraction/inversion
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12
Q

Abdominal Exam Sequence

A

Inspect > Auscultate > Percuss > Palpate (light then deep)

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13
Q

Key Subjective Data for Respiratory Health

A
  • Cough
  • SOB/SOA
  • Chest pain while breathing (inspiration or expiration)
  • Past hx of resp infections or allergies
  • Hx of smoking
  • Previous chest surgery
  • Environmental exposures
  • Self-care behaviors
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14
Q

Promoting Relaxation of Abdominal Muscles

A
  • Empty bladder
  • Warm room
  • Supine w/ knees bent
  • Hands on chest or at sides
  • Warm hands & steth
  • Distraction
  • Save painful for last
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15
Q

Inspection of Anterior Eye Structures

A
  • Cornea should be clear
  • Iris & pupil flat & equal
  • Direct & consensual
  • PERRLA: pupils equal, round, reactive to light & accommodation
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16
Q

Sounds of Abdominal Exam

A
  • Auscultation: gurging for 5-30 secs (not heard listen for 5 mins)
  • Percussion: dull over solid organs (liver), tympany over gas filled (intestines)
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17
Q

Scoliosis

A
  • Sideways “S” shaped
  • Potential Causes/Associated Factors: cerebral palsy, muscular dystrophy, birth defects, injuries
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18
Q

Breast Exam Data & Health Hx

A
  • Any pain, lumps, discharge, rashes, swelling, or trauma
  • Hx of breat disease
  • Surgery/radiation
  • Medications: female hormones
  • Self care: mammograms, BSE
  • Axilla: tender, lump, swelling, rash
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19
Q

Hypothyroidism

A
  • Intolerance to cold
  • Receding hairline
  • Facial & eyelid edema
  • Dull expression
  • Extreme fatigue
  • Thick tongue, slow speech
  • Anorexia
  • Brittle nail & hair
  • Hair loss
  • Dry skin
  • Muscle aches & weakness
  • Constipation
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20
Q

Breast Exam Techniques

A
  • For inspection hands: at side, above head, on hips, palms together, leaning forward
  • For palpation: vertical strip pattern, Spokes of a wheel, concentric circles pattern, palpating axilla, nipple squeeze for discharge
  • Bimanual Palpation: for large pendulous breast; lean forward, support lower part
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21
Q

Barrel Chest

A
  • Front & back of chest (anterior to posterior) is bigger than normal
  • 1:1 anterior to posterior
  • Potential Causes/Associated Factors: COPD, Emphysema, cystic fibrosis, arthritis
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22
Q

Modifiable Risk Factors for Breast Disease

A
  • Heavy alcohol consumption
  • Lack of physical activity
  • Never breastfed
  • Late age 1st pregnancy
  • Fatty diet
  • Obesity
  • Long term use of hormone therapy
  • Recent oral contraceptive use
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23
Q

Adventitious

A

Abnormal breath sounds

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24
Q

Palpate Anterior Chest

A
  • Symmetrical chest expansion
  • Tactile fremitus
  • Tenderness, masses, skin turgor, temp, & moisture
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25
Q

Inspection of External Eye Structures

A
  • Nonverbal signs of vision loss
  • Eyebrow, eyelid, & lash symmetry
  • Conjunctiva
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26
Q

Wheezes

A
  • Rhonchi
  • Means restricted airflow
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27
Q

Changes in Aging Adult for Head, Neck, & Face

A
  • Facial bones & orbits more prominent
  • Facial skin sagging
  • Dizziness
  • Neck pain
28
Q

Promotion of Cardiovascular Health

A
  • Screening for HTN
  • No smoking
  • Health BMI
  • No illicit drug use
  • Heart healthy diet; low Na, low fat, low chol, limit trans-fat
  • Healthy blood sugar (65-100)
  • Early screenings for family hx
  • Aerobic exercise
29
Q

Tachypnea

A

Rapid, shallow breathing rate

30
Q

Signs of Respiratory Distress

A
  • Use of accessory muscles
  • Pursed lip breathing
  • Excessive chest movement
31
Q

Changes in Aging Adult for Abdominal

A
  • Incrd abdom fat
  • Reduced salivation: dry mouth, dcrd taste
  • Incrd risk for aspiration
  • Dcrd gastric acid secretion: reduced vit D, iron, & calcium absorption
  • Incrd risk of gallstones
  • Liver size dcrs: impaired drug metabolism
  • Constipation due to reduced GI motility
32
Q

S1

A
  • Long, low-pitched
  • Loudest at apex
  • Closure of AV valves (tri & mi)
  • Beginning of systole (lub)
33
Q

Hyperthyroidism

A
  • Intolerance to heat
  • Bulging eyes
  • Enlarged thyroid
  • Tachycardia
  • Incrd systolic BP
  • Weight loss
  • Muscle wasting
  • Localized edema
  • Tremors
  • Clubbing
  • Incrd diarrhea
  • Menstrual changes
34
Q

Considerations for Aging Adult with Cardiac System

A
  • Widening pulse pressure
  • Check for orthostatic hypotension
  • Caution when palpating & auscultation carotid arteries
  • Incr murmurs
  • Incrd anteroposterior diameter
35
Q

Pleural Friction Rub

A
  • Low pitched
  • Leather rubbing together
  • Sound intensifies if stethoscope is pressed
  • Inspiratory & expiratory sounds
36
Q

Expected Findings of Breast Exam

A
  • Symmetric in size or shape, unless asymmetry is not new
  • Skin smooth w/ even color
  • Striae w/ pregnancy
  • Symmetric nipples; inversion normal if not new
37
Q

Palpate Posterior Chest

A
  • Symmetric expansion
  • Spinal alignment
  • Tactile fremitus
38
Q

Stridor

A
  • High pitched, monophonic inspiration crowing loudest in neck
  • Originates in larynx or trachea
  • Signifies an upper airway obstruction
  • Swelling or lodged foreign body
  • Frequently life threatening
  • ex: croup, epiglottitis
39
Q

Auscultation of Posterior Chest

A
  • Bronchial: expiration louder & longer
  • Bronchovesicular: inspiration & expiration abt equal
  • Vesicular: inspiration louder & longer
40
Q

Health Promotion & Education for Breast Health

A
  • Maintain healthy weigh & diet: fruits, veggies, whole grains, vit d and stress management & adequate sleep
  • Avoid red meats, sat fats, tobacco products & 2nd hand smoke
  • Minimize alcohol intake
  • Exercise
  • Breast feed infants
  • Annual CBE & Mammogram
  • Monthly SBE
41
Q

Percussion of Posterior & Anterior Chest

A

Normal percussion sound is RESONANCE over lungs

42
Q

Bruit

A

A soft blowing swishing sound that indicates blood flow turbulence

43
Q

Eye Assessment Data

A
  • Difficulty with vision: reduced acuity, blurring, blind spots
  • Pain of itching
  • Strabismus, diplopia
  • Redness or swelling
  • Use of glasses or contacts
  • Hx of ocular problems, glaucoma, or eye surgery
  • Watering or dishcarge
  • Hygiene practices
  • Date of last exam
  • Night vision problems, dcr in ADLs, difficulty climbing stairs or driving
44
Q

Pulse Rating System

A
  • 0 = absent
  • 1+ = weak
  • 2+ = normal
  • 3+ = incrd, full bounding
45
Q

Crackles

A
  • Rales
  • Means fluid
46
Q

Appearance (inspection) of Abdominal Exam

A
  • Flat, scaphoid (inverted), rounded, protuberant
  • Symmetry of contour, midline & inverted umbilicus
  • Skin color; striae, piercings, demeanor
47
Q

Inspecting Anterior Chest

A
  • Shape & configuration
  • Facial expression
  • Quality & RR
  • Skin color (any cyanosis; could mean dcrd oxygen, reduces LOC)
  • Resp effort: normal 10-20/min, even
48
Q

Biot Respiration

A

Regular deep respirations with periods of apnea

49
Q

Signs of Arterial Insufficiency

A
  • Deep muscle pain, pain w/ walking (claudication)
  • Cold, pale extremity
  • Dependent rubor
  • Reduced pulse intensity
  • Bruits
  • Thin shiny skin
  • Absence of hair
  • Distal gangrene
50
Q

Abdominal Assessment Data

A
  • Appetite
  • Dysphagia
  • Food intolerances
  • Pain
  • N/V
  • Bowel habits
  • Bloating or indigestion
  • Past surgeries or GI illnesses
  • Medications
  • Screening for colon CA
  • Nutrition
51
Q

Kyphosis

A
  • Curvature of spine towards top, “humpback”
  • Due to low activity and stretching
  • Common in older adults
  • Potential Causes/Associated Factors: osteoporosis, fractures, disk degeneration
52
Q

Properties of Arteries

A
  • Delivers oxygen & other nutrients in tissues
  • High pressure system
  • Thick walls
53
Q

Breast Exam Preparation - Mammogram

A
  • No deodorant, lotions, or powders
  • Schedule exam when not menstruating
  • Avoid excessive caffeine
54
Q

Auscultation of Anterior Chest

A
  • Work downward while comparing sides
  • Listen to full sounds
  • Bronchial: expiration louder & longer
  • Bronchovesicular: inspiration & expiration abt equal
  • Vesicular: inspiration louder & longer
55
Q

Inspecting Posterior Chest

A
  • Note configuration of thoracic cage
  • Pt’s basic body position
  • Pt’s color
  • Use of accessory muscles
56
Q

Bradypnea

A

Slow breathing rate; >12 breaths/min

57
Q

Hypoventilation

A

Shallow, slow breathing

58
Q

Auscultation of Heart Tones

A
  • Aortic Valve: 2nd ICS R sternal border (S2>S1)
  • Pulmonic Valve: 2nd INC L sternal border (S2>S1)
  • Erb’s Point: 3rd ICS L sternal border (S2=S1)
  • Tricuspid Valve: 4th or 5th ICS L sternal border (S1>S2)
  • Mitral Valve: 5th ICS mid-clavicular line (S1>S2)
59
Q

APE to Man

A

Aortic
Pulmonic
Erb’s Point
Tricuspid
Mitral

60
Q

Expected Changes in Aging Adults with Peripheral Vascular System

A
  • Dorsalis pedis & posterior tibial pulses difficult to find
  • Trophic skin changes w/ arterial insufficiency: thin shiny skin, thick-ridged nails, loss of hair
61
Q

How Does Systole Occur

A

Heart muscle contracts, ejects blood

62
Q

Head, Neck, & Face Assessment Data

A
  • Headaches
  • Hx of head injury, cosmetic, or cranial surgery
  • Dizziness (affecting ADLs?)
  • Neck pain (limiting ADLs or reduced ROM?)
  • Lumps or swelling
  • Hx of neck injury or surgery
63
Q

High Pitched Wheeze

A
  • High pitched, musical squeaking
  • Predominate in expiration, may occur in inspiration
64
Q

Signs of Venous Insufficiency

A
  • Pain worsens when standing
  • Dull aching
  • Tingling sensation
  • Varicose veins
65
Q

Pulmonary Complications in Aging Adult

A
  • Less mobile thorax
  • Dcrd resp muscle strength
  • Dcrd lung elasticity; dcrd vital capacity, incrd residual vol
  • Loss of intra-alveolar septa
  • Dcrd # of alveoli; less surface area for gas exhange
  • Incrd risk for dyspnea on exertion (DOE)
  • Incrd risk for postoperative pulm comps; atelectasis, infection
66
Q

Blood Flow Through Heart to Systemic Circ

A

SVC/IVC > RA > Tri Valve > RV > Pulm Valve > Pulm Artery > Lungs > Pulm Vein > LA > Mitral Valve > LV > Aortic Valve > Aorta > Systemic Circulation

NUR3120 HEALTH ASSESSMENT (3 decks)

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