Exam 2 Flashcards
general survey
physical appearance, body structure, mobility and behavior
physical appearence
age appropriate, sexual development, alert and oriented, skin tone, facial features are symmetric
body structure
height normal, adequate nutrition, weight, symmetry, posture, position, body build
mobility
gait and range of motion
behavior
facial expression, mood and affect, speech, dress, personal hygiene
when is body temp at low and high
diurnal cycle= 1-1.5 degree change with trough early morning and peak late afternoon to eve
Hyperthermia
Pyrogens secreted by bacteria during infection, tissue breakdown after tissue injury or death, neurological disorders that increase pressure on the brain
Hypothermia
Prolong exposure to cold, room temp IV fluids infused rapid, induced medically to decrease damage to tissue
Pulse assessment
Stroke volume, rate, rhythm, force, elasticity
Stroke volume
Amount of blood pumped by the heart with every beat
Rate of pulse
Normal 60-100 bpm
Bradycarida less than 60 bpm
Tachycardia greater than 100 bpm
Force of pulse
4 point scale, weak to bounding
Elasticity of pulse
Artery should feel straight springy and resilient
What causes weak pulse
Heart failure, hypovolemia, hypothermia, severe aortic stenosis
What causes bounding pulse
Fever, anemia, hyperthyroidism, bradycardia, aging, atherosclerosis
Systolic pressure
When heart contracts
Diastolic pressure
When heart is at rest
Pulse pressure
Difference btw systolic and diastolic pressure which reflects stroke volume (30-40 mm/hg)
Mean arterial pressure
The pressure that forces blood into tissues averaged over cardiac cycle, normal 80-100 mm/hg
SBP +2(DBP) / 3 = MAP
what all influences blood pressure?
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
Cardiac output
as more blood is pumped into blood vessels (increased CO), BP increases
Peripheral vascular resistance
constricted blood vessels increases BP because heart has to force blood against the increased resistance
Volume of circulating blood
more blood circulating or fluid in the blood circulating; greater BP
Viscosity
more blood cells and elements in blood; greater BP
Elasticity of vessel walls as they age
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
What is the proper method to take a clients blood pressure with a manual cuff?
Sphygmomanometer, correct width and size, place arm at heart level, proper inflation and deflation technique
How does the nurse determine the correct cuff size for a client?
Bladder length/arm circumference- 80% length and 40% circumference
Explain proper technique to assess for orthostatic hypotension.
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
Explain how to properly measure a clients BP in the thigh.
Normally higher then the arm
Have client lay and place cuff over popliteal artery with knee slightly bent.
What are lifestyle modifications to teach your client at the weight scale?
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
Acute pain is…
Sudden in onset
Usually subsides once treated
Occurs after injury to body
Labor pain, pain after traumatic injury, pain after surgery
Chronic pain is…
Persistent or recurring
Lasts longer than 6 months
Often difficult to treat
Vascular pain
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
Referred pain
Pain occurring away from the organ or origin
Neuropathic pain
Pain that results in the disturbance of function or pathological change in nerves
Phantom pain
Pain experienced in a body part that has been surgically or traumatically removed
Psychogenic pain
Pain that is psychological in nature but is truly real pain in terms of actual pain impulses that travel through nerve cells
Cancer pain
Pain resulting from any or a variety of causes related to cancer and/or metastasis of cancer
Central pain
Pain resulting from any disorder that causes damage to the CNS
Visceral pain
Pain that originates from organs or smooth muscle
Superficial pain
Pain that originates from the skin or mucous membrane
Somatic pain
Pain that originates from skeletal muscles, ligaments, or joints
Which type if pain can be perceived long after the site of injury has healed
Neuropathic pain- most difficult type of pain to assess and treat, neurochemical level
What are pain assessment questions the nurse should ask the client?
Where is your pain
When did the pain start
What does the pain feel like
What makes the pain better or worse
What are the 4 different pain scales
Numeric rating, descriptor, Wong-Baker FACES, CRIES
Nonverbal cues for acute pain
Guarding, grimacing, vocalization, moaning, agitation, restlessness, diaphoresis, change in VS
Nonverbal cues for chronic pain
Bracing, rubbing, diminished activity, change in appetite, sighing, signs of depression
What are consequences of poorly controlled acute pain?
Cardiac- increased BP, tachycardia Pulmonary- hyperventilation, dry cough GI Renal- decreased output, increased retention Musculoskeletal- spasm, joint stiffness CNS- anxiety, fatigue Immune Endocrine
What are the consequences of poorly controlled chronic pain?
Depression, isolation, limited mobility and function, confusion, family distress, decreased quality of life
Nutritional assessment purpose:
Identify person who is malnourished
Provide data for nutritional plan
Establish baseline data
Nutritional assessment methods:
Nutritional screening, comprehensive nutritional assessment, 24-hour diet recall, food frequency questionnaire, food diary, direct observation
Health history common nutritional problems (subjective)
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
Health history common nutritional problems (objective)
Intake and output Skin tugor Lung sounds Pitting edema Venous filling BP, Pulse
If cuff is too narrow you get a false
High blood pressure
Reflexive sympathetic dystrophy
Follows trauma to nerve, most common age 40-60, key= a light brush with cotton ball causes pain
Over weight BMI
25-29
Obesity BMI
30-39
What is the most accurate way to determine the size of the clients frame?
By elbow breadth (small medium or large)
Diaphoresis
Can be accompanied by fever, strenuous activity, cardiac or pulmonary disease or anything that elevates metabolic rate
Dehydration
Assess skin turgor which provides data to fluid volume balance. Also assess mucous membranes ( would be dry or cracked if inadequate nutrition)
Mobility and turgor of skin
Squeeze skin in stern all area or forearm and then release, if it takes 30 seconds or longer to return- poor turgor
How to assess edema
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
Capillary refill indicates
Peripheral circulation, normal is 1-2 seconds, abnormal is sluggish and longer than 2 seconds
Cherry angioma
Normal, small 1mm, smooth and slightly raised bright red dot on trunk or abdomen, increases as age over 30
ABCDE to assess skin
Asymmetry, Border, color and configuration, diameter and drainage, elevation and enlargement
Pallor
Light skin- Generalized and in conjunctivae and mucous membranes
Dark skin- assess sclerae, conjunctivae, buccal mucosa, tongue lips nails palms and sole
Erythema
Light- Skin is red or bright pink
Dark- palpate for warmth
Cyanosis
Light- Skin is dusky blue and nail beds dusky
Dark-examine conjunctivae, palms, soles, mucous membrane
Jaundice
Light- Yellow sclera, hard palate, mucous membranes, palms and soles
Dark- assess sclerae, hard palate
Edema on dark skin
Assess for decrease in color and palpate for tightness
Petechiae on dark skin
Look at areas with lighter pigmentation for purple/red dots
Rash on dark skin
Palpate for change in texture
Annular or circular skin lesions
Begins in circle and spreads to periphery, ring worm
Confluent lesions
Lesions run together, hives
Discrete lesions
Distinct separate lesions, wart or melanoma
Grouped lesion
Cluster of lesions, poison ivy
Gyrate lesion
Twisted coiled spiral
Target lesion
Resembles iris of eye, erythema multiforme
Linear lesion
Scratch line or stripe pattern
Zosteriform lesion
Linear arrangement along nerve route, herpes zoster or Shingles
Macular
Change in color of skin, flat examples are freckle, petechiae, measles, scarlet fever and ecchymoses from prolonged steroid use
Papule
Feel solid, less than 1 cm elevation, example wart or elevated mole
Vesicle
Blister filled with fluid
examples herpes zoster, contact dermatitis, early stage chicken pox
Nodule
Solid, elevated hard or soft >1 cm
Examples fibroma, intradermal nevi (mole)
Koilonchia
Spoon nails, may be from iron deficiency anemia
Paronychia
Bacterial infection under nail
Beau’s line
From trauma to nail
Splinter hemorrhage
Nail Bacterial endocarditis, infection of heart affecting valves
Late clubbing
Think long standing hypoxemia, nail abnormality
Onycholysis
Slow growing persistent fungal infection of the fingernails and toenails
Habit-tic dystrophy
From picking at cuticle frequently
Pitting of nail
Pitting and crumbling and distal detachment of nail from psorasis
Cultural considerations for the integumentary system
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
Common skin findings on dark skin
Keloids, pigmentary disorders (vitiligo), pseudofolliculitis, melasma
Keloids
Scars that grow beyond normal boundaries of the wound
Pigmentary disorders
Post inflammatory hypo or hyper- pigmentation appears as light or dark spots (vitiligo)
Pseudofolliculitis
Razor bumps or ingrown hair
Melasma
Patchy tan or dark brown discoloration on face due to pregnancy or hormones
objective data of the physical exam
symmetry, range of motion, lymph nodes, salivary glands (normally not palpable)
examining lymph nodes
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
preauricular
lymph node in front of ear
posterior auricular
lymph node on mastoid process
occipital
lymph node at base of skull
submental
lymph node midline behind the tip of the mandible
submandibular
lymph node halfway between angle and tip of the mandible
jugulodigastric
lymph node under angle of mandible
superficial cervical
lymph node overlies sternomastoid muscle
deep cervical
lymph node deep under sternomastoid muscle
posterior cervical
lymph node at the edge of the trapezius
supraclavicular
lymph node just above and behind clavicle at sternomastoid
what would follow the assessment of an abnormal lymph node?
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
temporal area
used to palpate temporal artery
temporal arteritis
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
tempomandibular joint
just below the temporal artery and anterior to the tragus. palpated with client mouth open and note normal smooth movement without tenderness or limitation.
abnormal tempomandibular joint
crepitation, limited ROM, tenderness
parotid glands
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
assessing trachea
place index finger on the trachea on sternal notch and slip fingers off to each side, should be symmetrical and trachea at midline
A large atelectasis will cause the trachea to
shift to the affected side
A tumor or pneumothorax will cause the trachea to
shift away from the affected side
assessing the thyroid gland
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
name the 12 cranial nerves
olfactory, optic, oculomotor, trochlear, abducens, trigeminal, facial, acoustic, glossopharyngeal, vagus, spinal accessory, hypoglossal
assessing olfactory nerve
test one nostril at a time with alcohol wipe or cotton with coffee
anosmia
decrease or loss of smell bilaterally b/c of smoking allergic rhinitis or cocaine use
neurologic anosmia
unilaterally loss of smell
assessing optic nerve
test visual acuity and visual fields, assess fundus of color size and shape of optic disc
assessing abducens
check pupil for size regularity equality direct and consensual light reaction and accommodation
assessing trigeminal (motor, sensory, and corneal reflex)
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
Assessing facial (motor and sensory)
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
Assessing acoustic (vestibulocolear)
test hearing acuity- whisper test, weber and Rinne tuning fork test
Assessing the vagus nerve (motor and sensory)
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
Assessing spinal accessory
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
Assessing the hypoglossal
stick your tongue out, ask to say light tight dynamite and note sound of letters L T D N are clear and distinct
