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Holistic Lecture > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

general survey

A

physical appearance, body structure, mobility and behavior

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2
Q

physical appearence

A

age appropriate, sexual development, alert and oriented, skin tone, facial features are symmetric

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3
Q

body structure

A

height normal, adequate nutrition, weight, symmetry, posture, position, body build

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4
Q

mobility

A

gait and range of motion

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5
Q

behavior

A

facial expression, mood and affect, speech, dress, personal hygiene

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6
Q

when is body temp at low and high

A

diurnal cycle= 1-1.5 degree change with trough early morning and peak late afternoon to eve

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7
Q

Hyperthermia

A

Pyrogens secreted by bacteria during infection, tissue breakdown after tissue injury or death, neurological disorders that increase pressure on the brain

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8
Q

Hypothermia

A

Prolong exposure to cold, room temp IV fluids infused rapid, induced medically to decrease damage to tissue

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9
Q

Pulse assessment

A

Stroke volume, rate, rhythm, force, elasticity

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10
Q

Stroke volume

A

Amount of blood pumped by the heart with every beat

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11
Q

Rate of pulse

A

Normal 60-100 bpm
Bradycarida less than 60 bpm
Tachycardia greater than 100 bpm

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12
Q

Force of pulse

A

4 point scale, weak to bounding

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13
Q

Elasticity of pulse

A

Artery should feel straight springy and resilient

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14
Q

What causes weak pulse

A

Heart failure, hypovolemia, hypothermia, severe aortic stenosis

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15
Q

What causes bounding pulse

A

Fever, anemia, hyperthyroidism, bradycardia, aging, atherosclerosis

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16
Q

Systolic pressure

A

When heart contracts

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17
Q

Diastolic pressure

A

When heart is at rest

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18
Q

Pulse pressure

A

Difference btw systolic and diastolic pressure which reflects stroke volume (30-40 mm/hg)

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19
Q

Mean arterial pressure

A

The pressure that forces blood into tissues averaged over cardiac cycle, normal 80-100 mm/hg

SBP +2(DBP) / 3 = MAP

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20
Q

what all influences blood pressure?

A

Age-gradual rise through childhood into adult years, Race- a black adult’s BP is higher than a white adult; hypertension is twice as high among blacks than whites, Weight- higher in obese, Emotions- increase BP while emotions are elevated, Gender- after puberty females are lower than males; after menopause females are higher, Diurnal rhythm- trough in morning and peak in late afternoon and early eve., Exercise- increases and then back to resting BP 5 mins. after exercise stopped, Stress- increases with stressors, such as pain, occupational stress, lifestyle stress

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21
Q

Cardiac output

A

as more blood is pumped into blood vessels (increased CO), BP increases

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22
Q

Peripheral vascular resistance

A

constricted blood vessels increases BP because heart has to force blood against the increased resistance

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23
Q

Volume of circulating blood

A

more blood circulating or fluid in the blood circulating; greater BP

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24
Q

Viscosity

A

more blood cells and elements in blood; greater BP

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25
Q

Elasticity of vessel walls as they age

A

as vessels age or become diseased they become stiff, non-elastic (non-compliant) making it harder for the heart to pump blood against the increased resistance; higher BP

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26
Q

What is the proper method to take a clients blood pressure with a manual cuff?

A

Sphygmomanometer, correct width and size, place arm at heart level, proper inflation and deflation technique

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27
Q

How does the nurse determine the correct cuff size for a client?

A

Bladder length/arm circumference- 80% length and 40% circumference

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28
Q

Explain proper technique to assess for orthostatic hypotension.

A

Client lays down for 2-3 minutes while nurse takes vitals laying down, sitting up and standing up.
significant if the BP drops >20mmHg, pulse increases 20bpm

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29
Q

Explain how to properly measure a clients BP in the thigh.

A

Normally higher then the arm

Have client lay and place cuff over popliteal artery with knee slightly bent.

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30
Q

What are lifestyle modifications to teach your client at the weight scale?

A 
Lose weight if more than 10% above ideal body weight
Limit alcohol intake 
Regular aerobic exercise 
Decrease salt intake 
Potassium, calcium, magnesium
Stop smoking 
Reduce saturated fats and cholesterol
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31
Q

Acute pain is…

A

Sudden in onset
Usually subsides once treated
Occurs after injury to body
Labor pain, pain after traumatic injury, pain after surgery

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32
Q

Chronic pain is…

A

Persistent or recurring
Lasts longer than 6 months
Often difficult to treat

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33
Q

Vascular pain

A

Pain that possibly originates from some pathology or the vascular or peripheral tissues and is thought to account for a large percentage of migraine headaches

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34
Q

Referred pain

A

Pain occurring away from the organ or origin

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35
Q

Neuropathic pain

A

Pain that results in the disturbance of function or pathological change in nerves

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36
Q

Phantom pain

A

Pain experienced in a body part that has been surgically or traumatically removed

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37
Q

Psychogenic pain

A

Pain that is psychological in nature but is truly real pain in terms of actual pain impulses that travel through nerve cells

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38
Q

Cancer pain

A

Pain resulting from any or a variety of causes related to cancer and/or metastasis of cancer

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39
Q

Central pain

A

Pain resulting from any disorder that causes damage to the CNS

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40
Q

Visceral pain

A

Pain that originates from organs or smooth muscle

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41
Q

Superficial pain

A

Pain that originates from the skin or mucous membrane

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42
Q

Somatic pain

A

Pain that originates from skeletal muscles, ligaments, or joints

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43
Q

Which type if pain can be perceived long after the site of injury has healed

A

Neuropathic pain- most difficult type of pain to assess and treat, neurochemical level

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44
Q

What are pain assessment questions the nurse should ask the client?

A

Where is your pain
When did the pain start
What does the pain feel like
What makes the pain better or worse

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45
Q

What are the 4 different pain scales

A

Numeric rating, descriptor, Wong-Baker FACES, CRIES

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46
Q

Nonverbal cues for acute pain

A

Guarding, grimacing, vocalization, moaning, agitation, restlessness, diaphoresis, change in VS

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47
Q

Nonverbal cues for chronic pain

A

Bracing, rubbing, diminished activity, change in appetite, sighing, signs of depression

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48
Q

What are consequences of poorly controlled acute pain?

A 
Cardiac- increased BP, tachycardia 
Pulmonary- hyperventilation, dry cough
GI
Renal- decreased output, increased retention 
Musculoskeletal- spasm, joint stiffness
CNS- anxiety, fatigue 
Immune
Endocrine
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49
Q

What are the consequences of poorly controlled chronic pain?

A

Depression, isolation, limited mobility and function, confusion, family distress, decreased quality of life

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50
Q

Nutritional assessment purpose:

A

Identify person who is malnourished
Provide data for nutritional plan
Establish baseline data

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51
Q

Nutritional assessment methods:

A

Nutritional screening, comprehensive nutritional assessment, 24-hour diet recall, food frequency questionnaire, food diary, direct observation

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52
Q

Health history common nutritional problems (subjective)

A 
Change in weight, decreases energy, problems with appetite or taste, dysphasia, diarrhea, constipation, nausea, vomiting, changes in skin color, hair, and nails
Previous illness
Current meds
Cultural/religious preferences
Eating patterns
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53
Q

Health history common nutritional problems (objective)

A 
Intake and output 
Skin tugor
Lung sounds
Pitting edema 
Venous filling 
BP, Pulse
54
Q

If cuff is too narrow you get a false

A

High blood pressure

55
Q

Reflexive sympathetic dystrophy

A

Follows trauma to nerve, most common age 40-60, key= a light brush with cotton ball causes pain

56
Q

Over weight BMI

A

25-29

57
Q

Obesity BMI

A

30-39

58
Q

What is the most accurate way to determine the size of the clients frame?

A

By elbow breadth (small medium or large)

59
Q

Diaphoresis

A

Can be accompanied by fever, strenuous activity, cardiac or pulmonary disease or anything that elevates metabolic rate

60
Q

Dehydration

A

Assess skin turgor which provides data to fluid volume balance. Also assess mucous membranes ( would be dry or cracked if inadequate nutrition)

61
Q

Mobility and turgor of skin

A

Squeeze skin in stern all area or forearm and then release, if it takes 30 seconds or longer to return- poor turgor

62
Q

How to assess edema

A

Imprint thumb on boney area; 1- mild pitting slight indent doesn’t appear swollen 2- moderate pitting, indent rapidly goes away 3- deep pitting indent stays short time leg looks swollen 4- very deep pitting indent stays long time leg very swollen

63
Q

Capillary refill indicates

A

Peripheral circulation, normal is 1-2 seconds, abnormal is sluggish and longer than 2 seconds

64
Q

Cherry angioma

A

Normal, small 1mm, smooth and slightly raised bright red dot on trunk or abdomen, increases as age over 30

65
Q

ABCDE to assess skin

A

Asymmetry, Border, color and configuration, diameter and drainage, elevation and enlargement

66
Q

Pallor

A

Light skin- Generalized and in conjunctivae and mucous membranes
Dark skin- assess sclerae, conjunctivae, buccal mucosa, tongue lips nails palms and sole

67
Q

Erythema

A

Light- Skin is red or bright pink

Dark- palpate for warmth

68
Q

Cyanosis

A

Light- Skin is dusky blue and nail beds dusky

Dark-examine conjunctivae, palms, soles, mucous membrane

69
Q

Jaundice

A

Light- Yellow sclera, hard palate, mucous membranes, palms and soles
Dark- assess sclerae, hard palate

70
Q

Edema on dark skin

A

Assess for decrease in color and palpate for tightness

71
Q

Petechiae on dark skin

A

Look at areas with lighter pigmentation for purple/red dots

72
Q

Rash on dark skin

A

Palpate for change in texture

73
Q

Annular or circular skin lesions

A

Begins in circle and spreads to periphery, ring worm

74
Q

Confluent lesions

A

Lesions run together, hives

75
Q

Discrete lesions

A

Distinct separate lesions, wart or melanoma

76
Q

Grouped lesion

A

Cluster of lesions, poison ivy

77
Q

Gyrate lesion

A

Twisted coiled spiral

78
Q

Target lesion

A

Resembles iris of eye, erythema multiforme

79
Q

Linear lesion

A

Scratch line or stripe pattern

80
Q

Zosteriform lesion

A

Linear arrangement along nerve route, herpes zoster or Shingles

81
Q

Macular

A

Change in color of skin, flat examples are freckle, petechiae, measles, scarlet fever and ecchymoses from prolonged steroid use

82
Q

Papule

A

Feel solid, less than 1 cm elevation, example wart or elevated mole

83
Q

Vesicle

A

Blister filled with fluid

examples herpes zoster, contact dermatitis, early stage chicken pox

84
Q

Nodule

A

Solid, elevated hard or soft >1 cm

Examples fibroma, intradermal nevi (mole)

85
Q

Koilonchia

A

Spoon nails, may be from iron deficiency anemia

86
Q

Paronychia

A

Bacterial infection under nail

87
Q

Beau’s line

A

From trauma to nail

88
Q

Splinter hemorrhage

A

Nail Bacterial endocarditis, infection of heart affecting valves

89
Q

Late clubbing

A

Think long standing hypoxemia, nail abnormality

90
Q

Onycholysis

A

Slow growing persistent fungal infection of the fingernails and toenails

91
Q

Habit-tic dystrophy

A

From picking at cuticle frequently

92
Q

Pitting of nail

A

Pitting and crumbling and distal detachment of nail from psorasis

93
Q

Cultural considerations for the integumentary system

A

Sparse body hair common for Asian (males have less facial hair), increase Mongolian spots of sacral area of Chinese Native American an African American newborns, nose piercing may be cultural, Arabic and Indian females use henna, Sikhs are prohibited to remove or cut hair, may require covering of head such as Muslims or Orthodox Jews

94
Q

Common skin findings on dark skin

A

Keloids, pigmentary disorders (vitiligo), pseudofolliculitis, melasma

95
Q

Keloids

A

Scars that grow beyond normal boundaries of the wound

96
Q

Pigmentary disorders

A

Post inflammatory hypo or hyper- pigmentation appears as light or dark spots (vitiligo)

97
Q

Pseudofolliculitis

A

Razor bumps or ingrown hair

98
Q

Melasma

A

Patchy tan or dark brown discoloration on face due to pregnancy or hormones

99
Q

objective data of the physical exam

A

symmetry, range of motion, lymph nodes, salivary glands (normally not palpable)

100
Q

examining lymph nodes

A

use finger pads and gently in a circular motion to palpate, use both hands to compare sides, normally they are soft moveable and tender, abnormal to be enlarged and may not be tender

101
Q

preauricular

A

lymph node in front of ear

102
Q

posterior auricular

A

lymph node on mastoid process

103
Q

occipital

A

lymph node at base of skull

104
Q

submental

A

lymph node midline behind the tip of the mandible

105
Q

submandibular

A

lymph node halfway between angle and tip of the mandible

106
Q

jugulodigastric

A

lymph node under angle of mandible

107
Q

superficial cervical

A

lymph node overlies sternomastoid muscle

108
Q

deep cervical

A

lymph node deep under sternomastoid muscle

109
Q

posterior cervical

A

lymph node at the edge of the trapezius

110
Q

supraclavicular

A

lymph node just above and behind clavicle at sternomastoid

111
Q

what would follow the assessment of an abnormal lymph node?

A

the examiner should be familiar with the direction of drainage patterns of the system. the area proximal (upstream) to the location of the abnormal node is explored

112
Q

temporal area

A

used to palpate temporal artery

113
Q

temporal arteritis

A

the artery is tortuous, hard, and tender. pt will have visual disturbance such as diplopia, loss of vision or blurred vision b/c of decrease blood to the eye

114
Q

tempomandibular joint

A

just below the temporal artery and anterior to the tragus. palpated with client mouth open and note normal smooth movement without tenderness or limitation.

115
Q

abnormal tempomandibular joint

A

crepitation, limited ROM, tenderness

116
Q

parotid glands

A

salivary glands in cheeks over the mandible, anterior to and below the ear. Can be enlarged with mumps(either one or both) can be enlarged with AIDS

117
Q

assessing trachea

A

place index finger on the trachea on sternal notch and slip fingers off to each side, should be symmetrical and trachea at midline

118
Q

A large atelectasis will cause the trachea to

A

shift to the affected side

119
Q

A tumor or pneumothorax will cause the trachea to

A

shift away from the affected side

120
Q

assessing the thyroid gland

A

auscultate for bruit using the bell, a positive bruit means turbulent blood flow with hyperthyroidism, enlarged thyroid 5mm or larger seen with hyper or hypo, labs: TSH T3 T4 Calcitonin levels

121
Q

name the 12 cranial nerves

A

olfactory, optic, oculomotor, trochlear, abducens, trigeminal, facial, acoustic, glossopharyngeal, vagus, spinal accessory, hypoglossal

122
Q

assessing olfactory nerve

A

test one nostril at a time with alcohol wipe or cotton with coffee

123
Q

anosmia

A

decrease or loss of smell bilaterally b/c of smoking allergic rhinitis or cocaine use

124
Q

neurologic anosmia

A

unilaterally loss of smell

125
Q

assessing optic nerve

A

test visual acuity and visual fields, assess fundus of color size and shape of optic disc

126
Q

assessing abducens

A

check pupil for size regularity equality direct and consensual light reaction and accommodation

127
Q

assessing trigeminal (motor, sensory, and corneal reflex)

A

motor-client clenches teeth, muscles of mastication, should be strong and unable to open mouth by pushing on chin, sensory- wisp cotton ball light touch to ophthalmic maxillary and mandibular area with clients eyes closed, corneal reflex- omit unless client has abdominal facial sensation or movement

128
Q

Assessing facial (motor and sensory)

A

motor-symmetry in smile frown closing eyes lift eyebrows show teeth puff cheeks, sensory- only test if suspicion of facial nerve injury would use cotton with sweet sour and salty

129
Q

Assessing acoustic (vestibulocolear)

A

test hearing acuity- whisper test, weber and Rinne tuning fork test

130
Q

Assessing the vagus nerve (motor and sensory)

A

motor- depress tongue say ahhh uvula and soft palate should rise in midline and tonsillar pillars should move medially, check gag reflex and for normal sound of voice; sensory- don’t need to test but CN IX is involved with taste

131
Q

Assessing spinal accessory

A

client rotates head against your hand placed at side of face and chin on each side, shrug shoulders against resistance of your hands, test sternomastoid and trapezius muscles

132
Q

Assessing the hypoglossal

A

stick your tongue out, ask to say light tight dynamite and note sound of letters L T D N are clear and distinct

Holistic Lecture (4 decks)

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