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Health Assessment > Exam 2 > Flashcards

Exam 2 Flashcards

vital signs, lungs & thorax, abdomen

1
Q

Visceral pain origin

A

originates from larger interior organs

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2
Q

Visceral pain presents

A

autonomic responses - vomiting, nausea, pallor, diaphoresis

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3
Q

Visceral pain occurs from

A

direct injury or stretching of organ

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4
Q

Deep somatic pain origin

A

blood vessels, joints, tendons, mm, bone

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5
Q

Deep somatic pain presents

A

nausea, sweating, tachycardia, HTN, aching, throbbing

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6
Q

Deep somatic pain is usually

A

well localized and able to be identified

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7
Q

Cutaneous pain origin

A

skin surface, subcutaneous tissues

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8
Q

Cutaneous pain feels

A

sharp, burning sensation

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9
Q

Referred pain origin

A

visceral or somatic structures

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10
Q

Referred pain localization

A

felt at particular site but originates from another - same innervation

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11
Q

Acute pain

A

short term, self limiting, protective purpose

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12
Q

Acute incident pain

A

occurs predictably with certain movements

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13
Q

Acute pain behaviors

A

autonomic response - guarding, grimacing, vocalizations, diaphoresis, change in vital signs

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14
Q

Chronic pain

A

persistent, 6+ months, those with chronic pain are often not believed

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15
Q

Chronic pain behaviors

A

bracing, rubbing, diminished activity, sighing, appetite change, more variable than acute behaviors

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16
Q

Pain as subjective

A

self report is gold standard of pain assessment, pain is always subjective

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17
Q

Infant pain assessment

A
  • preverbal and incapable of self-report
  • depends on behavioral/psychological cues
  • CRIES: neonatal postoperative pain measurement score
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18
Q

Children pain assessment

A
  • children 2+ can report pain but not intensity
  • rating scales introduced at 4-5 age
  • FLACC
  • faces pain scale
  • consult caregivers
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19
Q

Temperature is influenced by

A

diurnal cycle - lower in morning
menstruation - higher when ovulating
exercise - higher
age - lower in older adults, varies in kids

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20
Q

Expected oral temperature

A

98.6, range of 96.4-99.1

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21
Q

Oral temperature is

A

accurate and convenient

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22
Q

Expected rectal temperature

A

.7-1 F higher than oral

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23
Q

Rectal temperature is

A

most accurate, closest to core temp, invasive

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24
Q

Tympanic temperature is

A

noninvasive, nontraumatic, quick, efficient, may be less accurate during cardiac arrest

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25
Q

Pinna positioning for temperature

A

adult: up and back
child: straight down

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26
Q

Temperature tips

A
  • red tip probe for rectal
  • blue tip for oral/axillary
  • wait 15 min after hot/cold liquid ingestion
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27
Q

If pulse rhythm is irregular

A

count pulse for full minute

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28
Q

Expected HR

A

50-95bpm, higher the younger you are

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29
Q

HR factors

A
  • medications - may slow hR
  • age: slows with age
  • gender: slightly faster in females after puberty
  • athletes: lower
  • anxiety: high HR
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30
Q

Respirations should be

A

relaxed, regular, automatic, silent

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31
Q

Expected RR

A

20 breaths/min, 16-25 range

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32
Q

As you age, RR becomes

A

slower

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33
Q

Pulse oximeters measure

A

the relative amount of light absorbed by HbO2 and unoxygenated HB

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34
Q

Expected SpO2 on room air

A

97-99%

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35
Q

Pulse oximeter placement

A
  • translucent skin (finger, toe, pinna)
  • infants: foot, big toe, palm, thumb
  • remove any polish
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36
Q

Systolic pressure is

A

maximum pressure felt on artery during L ventricular contraction

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37
Q

Ideal systolic

A

90-119mmHg

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38
Q

Diastolic pressure is

A

pressure that blood exerts constantly between each contraction

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39
Q

Ideal diastolic

A

50-80mmHg

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40
Q

Pulse pressure

A

difference between systolic and diastolic - reflects stroke value

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41
Q

Mean arterial pressure

A

pressure forcing blood into tissue

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42
Q

Factors of BP

A
  • age: gradual rise
  • sex: in females, lower after puberty and higher after menopause
  • race
  • social determinants: low socioeconomic status = higher risk
  • diurnal rhythm
  • weight: obesity increases BP
  • exercise, emotions, stress
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43
Q

Level of BP is determined by 5 factors

A
  1. CO: increase CO, increase BP
  2. Peripheral vascular resistance: vasoconstriction increases BP
  3. Volume of circulating blood: fluid retention increases BP
  4. Viscosity: increase viscosity, increase BP
  5. Elasticity of vessel: increase rigidity, increase BP
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44
Q

Measuring BP

A
  • width of cuff should equal 40% arm circumference
  • length of cuff = 80% circumference
  • keep arm at heart level
  • uncross legs
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45
Q

What leads to high BP readings

A
  • narrow cuff size
  • applied too loose
  • reinflating during procedure
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46
Q

What leads to low BP readings

A
  • decreased inflation
  • cuff size too large
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47
Q

Orthostatic vital signs indication

A
  • suspect volume depletion
  • known hypertension
  • reports fainting/syncope
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48
Q

BP from sitting to standing

A

slight decrease in systolic

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49
Q

Infant/children vital signs

A
  • BP not normally checked in kids <3
  • avoid rectal
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50
Q

Infant vital sign order

A

reverse order to respirations, pulse, temperature

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51
Q

Preschooler vital signs

A

consider normal fear of body mutilation may increase with any invasive procedureS

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52
Q

School age vital signs

A

promote cooperation by explanation and participation

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53
Q

Infants/children pulse

A
  • palpate or ausculate an apical rate with infants + toddlers
  • in children 2+, use radial site
  • count pulse for full minute
  • fluctuates
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54
Q

Infant/children respirations

A
  • watch infant’s abdomen for movement
  • sleeping RR most accurate in infants
  • count for full minute
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55
Q

Thorax anatomy

A

posterior chest, anteroposterior to transverse ratio of 1:2 or 5:7

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56
Q

L vs R lung

A

L lung is narrower, 2 lobes
R lung is shorter, 3 lobes

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57
Q

Anterior lungs

A

almost all upper/middle lobes
apex of lungs is 3-4 cm above inner third clavicle

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58
Q

Posterior lungs

A

C7-T10
almost all lower lobes

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59
Q

Reference points

A

midclavicular line, anterior axillary lines, midsternal line, scapular line, vertebral line

60
Q

Pleura

A

thin, slippery serous membrane enveloping the lungs, filled with lubricating fluid to help lungs during breathing

61
Q

Trachea/bronchi function

A

transport gasses between environment and lungs

62
Q

Gas exchange occurs in

A

alveoli and alveolar duct

63
Q

Functions of breathing

A

supply oxygen, remove co2, maintain homeostasis, maintain heat exchange

64
Q

Acid-base balance of blood

A

maintain pH of 7.4
- lungs help maintain balance by adjusting level of CO2
- hyperventilation decreases CO2, hypoventilation increases CO2

65
Q

Hypercapnia

A

increase CO2, stimulus for us to breathe

66
Q

Hypoexemia

A

decrease O2, also a stimulus to breathe

67
Q

Tachypnea

A

rapid shallow breathing, >24 breaths/min

68
Q

Tachypnea causes

A

fever, fear, exercise

69
Q

Bradypnea

A

slow breathing, decreased but regular HR

70
Q

Bradypnea causes

A

drug-induced, increased intracranial pressure

71
Q

Hyperventilation cause

A

extreme exertion, fear, anxiety, DKA

72
Q

Hypoventilation causes

A

overdose of narcotics, anesthesia

73
Q

Cheyne-stokes

A

respirations gradually wax and wane

74
Q

Health history of lungs

A

cough, sputum, shortness of breath, allergies, chest pain, smoking, environmental considerations

75
Q

Lung inspection

A

skin color, work to breath, accessory mm use, RR, respiratory pattern, shape/configuration of chest wall

76
Q

Lung inspection expected findings

A
  • straight spin, symmetric scapula and thorax, ribs slope downward at 45 degrees
  • AP to transverse diameter ratio is .7-.75
77
Q

Barrel chest

A

ap diameter = transverse diameter
- occurs in normal aging as lungs become more rigid
- worse with chronic emphysema and asthma

78
Q

Infant/children lung inspection

A
  • assess for nasal flaring, grunting, blue lips
  • barrel chest normal until 6
  • may note abdominal breathing or irregular breath
  • infants are obligatory - nose breather until 3 months
  • intercostal retractions
79
Q

Intercostal retractions

A

inward movement of mm between ribs from reduced pressure in chest cavity - sign of difficulty breathing

80
Q

Lung Palpate goal

A

symmetric expansion

81
Q

Anterior lung palpation

A

place hands along costal margins with thumbs pointing toward xiphoid process

82
Q

Posterior lung palpation

A

place hands on posterior chest sideways with thumbs together at T9-T10

83
Q

Lung palpation method

A
  • slide hands medially to pink small fold of skin between thumbs
  • ask person to take deep breath
  • as person inhales, thumbs should move apart symmetrically
  • note any lag in expansion
  • unequal expansion = part of lung is obstructed/collapsed
84
Q

Lung auscultation

A
  • have patient sitting, leaning slightly forward with hands in lap
  • breath through mouth
  • listen one full respiration at each location
  • silent chest = no air moving in or out
85
Q

Adventitious sounds

A

extra sounds not normally heard

86
Q

Fine crackles (rales)

A

high-pitched, short cracking, popping sounds during inspiration that aren’t cleared with coughing

87
Q

Coarse crackles

A

loud, low-pitched, bubbling, gurgling

88
Q

Atelactatic crackles

A

fine crackles that don’t last and are not pathologic
- often older patients, bedridden, just waking up

89
Q

Rhonchi

A

low-pitched, musical, snoring sound from airflow obstruction from secretions

90
Q

Stridor

A

high-pitched, monophonic, inspiratory crowing sound
- louder in neck than chest wall
- caused by croup in kids or foreign airway obstruction

91
Q

Pleural friction rub

A

superficial sound that’s coarse, low-pitched, grating quality
- louder the harder you push your stethoscope
- inspiratory and expiratory

92
Q

Wheezing

A

high-pitched, musical, squeaking lung sound, sometimes clears with coughing

93
Q

Preparing for abdominal assessment

A
  • adequate lighting
  • maintain privacy
  • empty bladder, warm stethoscope, examine painful areas last
  • auscultate before percussion/palpation
94
Q

Contour

A

describes nutritional status and normally ranges from flat to protuberant

95
Q

Abdomen inspection

A

stand on right side and look down on abdomen, then stoop to gaze across abdomen

96
Q

Scaphoid abdomen

A

caves in

97
Q

Protuberant abdomen indicates

A

distention

98
Q

Inspecting abdomen symmetry

A
  • should be symmetric bilaterally
  • note any bulging, visible mass, asymmetric shape
  • step to foto of bed to recheck symmetry
  • hernia
99
Q

Hernia

A

protrusion of abdominal viscera through abdominal opening in mm wall

100
Q

Abdomen inspection - umbilicus

A
  • should be midline and inverted with no discoloration, inflammation, or hernia
101
Q

Abdomen umbilicus can be everted with

A

pregnancy, ascites, or underlying masses

102
Q

Abdomen umbilicus can be deeply sunken if

A

obese

103
Q

Abdomen umbilicus may be blue if

A

intraperitoneal bleeding (Cullen sign)

104
Q

Abdomen inspection - skin

A

should be smooth, even, appropriate for ethnicity

105
Q

Unexpected abdomen skin findings

A

redness (localized infection), jaundice, skin glistening and taut (ascites)

106
Q

Expected pulsations/movement of abdomen

A

may see aortic pulsations or waves of peristalsis in thin people

107
Q

Unexpected pulsations or movement in abdomen

A

marked aortic pulsations could indicate hypertension, aortic insufficiency, or aneurysm

108
Q

Distended abdomens may have

A

marked pulsations

109
Q

Abdomen inspection - expected demeaner

A

relaxed, quietly with benign facial expression and slow, even respirations

110
Q

Abdomen inspection - unexpected demeanor

A
  • restlessness/turning (gastroenteritis or bowel obstruction)
  • absolute stillness/resisting movement (pain of peritonitis)
  • knees flexed, facial grimacing, rapid respirations (pain)
111
Q

Auscultation should occur

A

before percussion and palpation

112
Q

Auscultation uses this part of the stethoscope and method

A

diaphragm
- bowel sounds are high-pitched
- hold lightly against skin
- begin in RLQ at ileocecal valve area

113
Q

Abdomen auscultation expected findings

A

normoactive bowel sounds, occur irregularly 5-30 times/minute

114
Q

Unexpected abdomen auscultation findings

A

Hyperactive sounds, borborygmus, hypoactive sounds, absent sounds

115
Q

Hyperactive sounds are

A

loud, high-pitched, rushing, tinkling
- increased motility

116
Q

Hypoactive sounds could follow

A

abdominal surgery or inflammation of peritoneum

117
Q

Absent sounds are

A

uncommon, listen for full 5 minutes before you determine absence

118
Q

RLQ parts

A

cecum, appendix, R ovary + tube, R ureter, R spermatic cord

119
Q

RUQ parts

A

liver, gallbladder, duodenum, head of pancreas, R kidney + adrenal gland, hepatic flexure of colon, part of ascending + transverse colon

120
Q

LUQ parts

A

stomach, spleen, L liver lobe, body of pancreas, L kidney + adrenal gland, splenic flexure of colon, part of transverse + descending colon

121
Q

LLQ parts

A

part of descending colon, sigmoid colon, L ovary + tube, L ureter, L spermatic cord

122
Q

dyphagia

A

difficulty swallowing

123
Q

pyrosis

A

heartburn

124
Q

eructation

A

burp

125
Q

hematemesis

A

vomiting blood

126
Q

pica

A

eating non-food items

127
Q

melena

A

black, tarry stool containing blood - internal bleeding

128
Q

grey stools

A

bleeding, bile deficiency, jaundice

129
Q

Bruits are

A

vascular sounds

130
Q

Bruits method + expected findings

A
  • listen with bell
  • listen over aorta, renal, iliac, femoral arteries
  • usually won’t hear any sounds
131
Q

Abnormal bruit sounds

A

blowing, rushing - occurs with stenosis, occlusion, or anuerysm of artery

132
Q

Abdominal percussion goal

A

assess relative density of abdominal contents, locate organs, screen for fluid or masses

133
Q

Abdominal percussion method

A

proceed lightly in all 4 quadrants in clockwise pattern, starting with RLQ

134
Q

Abdominal percussion expected findings

A

general tympany x 4 quadrants

135
Q

Abdominal percussion unexpected findings

A

Dullness or hyperresonance
- distended bladder, adipose tissue, fluid, mass
- hyperresonance = gas

136
Q

Costovertebral angle tenderness

A

positive findings indicate kidney inflammation

137
Q

Costovertebral angle tenderness process

A
  • indirect fist percussion causes tissues to vibrate
  • place 1 hand over 12th rib at CVA on back
  • make fist with other hand
  • thump flat hand with ulnar edge of fist
  • normal person feels no pain
  • kidney infection = intense pain
138
Q

Abdominal palpation goal

A

judge size, location, consistency of organs and screen for abnormal masses/tenderness

139
Q

Abdominal palpation method

A
  • use measure to relax patient, enhance mm relaxation
  • begin with light palpation and proceed to deep plapation
140
Q

Light abdominal palpation

A
  • 1cm
  • overall impression of skin surface and superficial musculature
  • entire abdomen, clockwise, zigzag pattern
  • save tender areas for last
141
Q

Deep abdominal palpation

A
  • 5-8cm
  • note tenderness, location, size, consistency, and mobility of any abnormal findings
142
Q

Expected abdominal findings

A
  • soft, non tender to palpation x 4 quadrants
  • no masses or tenderness
  • voluntary guarding
143
Q

Unexpected abdominal findings

A
  • distended abdomen
  • tender
  • involuntary guarding or rigidity
144
Q

Voluntary guarding

A

cold, tense, ticklish - use relaxation techniques

145
Q

Involuntary guarding

A

constant board like hardness of mm
- protective mechanism from acute inflammation of peritoneum

146
Q

Common causes of constipation

A

decreased activity, inadequate water intake, low-fiber, medication side effects, hypothyroidism, inadequate toilet facilities

147
Q

Abdomen nursing considerations

A
  • don’t palpate a patient’s abdomen who has had an organ transplant
  • don’t feed patient until they’ve passed flatus
  • acute abdominal pain needs immediate assessment

Health Assessment (4 decks)

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