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NURS 319 Health Assessment UMSON > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Preauricular lymph node location

A

In front of the ear

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2
Q

Posterior auricular lymph node location

A

Behind the ear

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3
Q

Occipital lymph node location

A

Base of the back part of skull

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4
Q

Submental lymph node location

A

Underneath chin

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5
Q

Submandibular lymph node location

A

Halfway between the angle and the tip of the mandible

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6
Q

Juggulodigastric lymph node location

A

Under the angle of the mandible

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7
Q

Superficial cervical lymph node location

A

Overlying the external mastoid muscle

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8
Q

Deep cervical lymph node location

A

Deep under the external mastoid muscle

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9
Q

Posterior cervical lymph node location

A

And the posterior triangle along the edge of the trapezius muscle

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10
Q

Supraclavicle lymph node location

A

Just above and behind the clavicle at the external mastoid muscle

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11
Q

How do you assess the trachea

A

through palpation normally the trachea is midline and slightly movable inspect and palpate for any shift note and deviation from midline

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12
Q

Hyperventilation

A

Increase in rate and depth of breath

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13
Q

Techypnea

A

Faster breathing

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14
Q

Bradypnea

A

Decreased respiration less than 10 breasts per minute

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15
Q

Orthopnea

A

Trouble breathing while in a lying down position

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16
Q

Dyspnea

A

Difficulty breathing

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17
Q

Hypercapnia

A

Excessive amount of CO2

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18
Q

Hypoxemia

A

Lack of oxygen

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19
Q

Cheyne-stokes

A

Increase in breathing then decrease in breathing followed by a period of apnea. Usually happens at the end of life.

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20
Q

how to assess thorax and lungs

A

Inspect palpation percussion ausculation

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21
Q

Thorax and lungs inspection

A

Shape and symmetry of chest

Posture/position used to breath

Respiratory rate

Rhythm

Skin color and condition

Lung expansion

Use of accessory muscles

Clubbing

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22
Q

Posture/position used to breath thorax and lung assessment

A

Which includes a relaxed posture and the ability to support one’s own weight. (Tripod Position - which is seen a lot in COPD patients which is where they lean forward to breathe) Neck Muscles are also hypertrophied due to the aid of forced respiration across the obstructed airway.

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23
Q

Respiratory rate thorax and long assessment

A

Norm al is 12 to 20 breaths per minute braided is less than 10 breast per minute and tachypnea is less than 24 breast per minute

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24
Q

Shape and symmetry of chest thorax and lung assessment

A

anterior-posterior (AP) to transverse diameter; which should be less than transverse, 3/4 in adults. barrel chest is when the AP is equal to transverse diameter which is caused by hyperinflation of lung (Barrel chest common in COPD constant lack of inspiration scoliosis and kyphosis)

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25
Q

Rhythm thorax and lung assessment

A

Bradypnea, tachypnea, hyperventilation, normal

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26
Q

Skin color and condition thorax and long assessment

A

Color could be consistent with the person’s background with allowance for sun exposure areas on the chest and back lips nails and mucous membrane. This is the best place to do a skin and pigment assessment due to its usual lack of exposure from the sun.

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27
Q

Cyanosis

A

The turning of blue due to the lack of O2 in the body

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28
Q

Use of accessory muscles thorax and lung inspection

A

No reaction or bulging of the interspace should occur on inspiration normally accessory muscle is not used during a augment respiratory

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29
Q

Clubbing thorax and lung inspection

A

Increased size and fanning of fingers and fingernails due to a chronic respiratory disease

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30
Q

Palpation thorax and lung inspection

A

Tenderness or crepitus

Symmetry of lung expansion

Assess tactile fremitus

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31
Q

Tenderness or crepitus lung and thorax palpation

A

Looking for tenderness and crepitus air bubbles or crackling under the skin

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32
Q

Symmetry of lung thorax and lung palpation

A

By placing your warmed hand sideways on the posterior lateral chest wall with thumb pointed together at the T9-T10. Slide your hand immediately to pinch up a small fold of skin between your thumbs ask the person to take a deep breath and as your patient inhales deeply your thumbs should move apart symmetrically

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33
Q

Assess tactile fremitus

A

Move hands across and down either the chest or the back have the patients say either 99 or blue moon these words produce strong vibrations. Each side should have the same vibrations.

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34
Q

Percussion thorax and lung

A

Resonance

Dull

Flat

Hyper resonance

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35
Q

Resonance percussion sound meaning

A

Low-pitched clear hollow sound. Normally found in lungs.

36
Q

Dull percussion sound

A

Fluid sound normally found in liver, heart, spleen abnormal in lung

37
Q

Flat percussion sound

A

Should be heard over muscles and bones

38
Q

Hyper resonance percussion sound

A

Low-pitched booming sound found when too much air is present such as emphysema and or pneumothorax

39
Q

Ausculation lung and thorax

A

Three types of normal breathing sounds found in older children and adults.
Bronchial
Bronchialvesicular
Vesicular

40
Q

Ausculation Lung and thorax bronchial

A

Also known as tracheal. Loudest inspiration harsh hollow tubular

41
Q

Ausculation Lung and thorax broncovesicular

A

Moderate, inspiration equals expiration, mix sound, major bronchi very few alveoli

42
Q

Ausculation Lung and thorax vesicular

A

Softest, expiration, rustling sound small bronchioles and alveoli

43
Q

Stridor lung sound

A

High pitched whistling sound heard when taking a breath. Caused by blockage in trachea

44
Q

Wheezing lung sound

A

Whistling sound due to narrowing of airways caused by edema and asthma

45
Q

Rhonchi lung sound

A

Rattling sound in larger airways of lung caused by excessive mucus

46
Q

Rales long sound

A

Bubbling sound heard in small airways alveoli typically when they fill with fluid

47
Q

Assessment finding for asthma

A

Inspection - increased respiratory rate shortness of breath audible wheeze cyanosis

Palpation-tactical fremitus decrease, tachycardia.

Percussion - resonant or hyper resonant if it’s chronic asthma.

Auscultation- breathing sounds decreased, voice sounds decreased prolonged expiration

48
Q

Pneumonia assessment findings

A

Inspection - respiration of 24 per minute or more, guarding, lack of expansion on affected side.

Palpation pulse greater than 100 beats per minute, chest expansion decrease on affected side.

Percussion - Dull over pneumonia area

Auscultation - tachycardia, loud bronchial breathing, voice sounds have increased clarity, fine medium crackle.

49
Q

Emphysema assessment findings

A

Inspection - increased AP diameter (barrel chest) tripod position.

Palpation - decreased tactile fremitus and breathing sounds.

Percussion - hyper resonant.

Auscultation- muffled heart sound, decrease breath sound, may have an occasional wheeze.

50
Q

Abdominal assessment

A

Inspection, auscultation, percussion, palpation

51
Q

Abdominal assessment inspection

A

Shape, symmetry, umbilical, skin, pulsation and movement, hair distribution, demeanor

52
Q

Auscultation abdominal assessment

A

Bowel sounds-high pitch gurgling, cascading sounds heard five to 30 times per minute.

vascular sounds- check the aorta, femoral, iliac, renal artery. No sound is normal. However younger patients may have a brew it from the artery medium to low and pitch and hurt between the xiphoid process and belly button.

53
Q

Abdominal assessment percussion

A

General tympany, liver span, splenic dullness, costovertebral angle tenderness, fluids, fluid wave, shifting dullness

54
Q

Abdominal assessment palpation

A

Liver, spleen, kidney, aorta

55
Q

Borborygmus

A

Stomach growling, hyperparastalsis

56
Q

Dysphagia

A

Difficulty swallowing

57
Q

Bruits

A

Vascular sounds

58
Q

Ascites

A

Free fluid in the peritoneal cavity occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, cancer

59
Q

Striae

A

Pink / blue to silvery white linear and jagged lines found on the abdomen

60
Q

Hernia

A

A loop of bowel or content protruding through a weak spot in the abdominal muscle

61
Q

Concave contour

A

Shape of belly curves inward

62
Q

Protuberance

A

A sign of distension in the abdomen

63
Q

Scaphoid

A

Abdominal caving

64
Q

Right upper quadrant organs

A

Liver, gallbladder, duodenum, head of pancreas, write adrenal gland, portion of right kidney, part of ascending and transverse colon

65
Q

Organs in right lower quadrant

A

Cecum, appendix, right ovary and fallopian tube, right ureter, lower pole of right kidney, portion of ascending colon, right spermatic cord, bladder if distended

66
Q

Organs and left upper quadrant

A

Stomach, spleen, left lobe of liver, body of pancreas, left adrenal gland, portion of left kidney, portion of transverse and descending colon

67
Q

Organs in the left lower quadrant

A

Lower pole of left kidney, portion of descending colon, sigmoid colon, bladder, leftovery, left fallopian tube, left spermatic cord

68
Q

Abdominal assessment

A

Blumberg’s sign, Murphy sign, ilipsoas muscle test, obturator test

69
Q

Blumberg sign

A

When you push down slowly and deeply and pull up quickly pain should be felt when pulling up. This test should be performed last due to cause of pain and muscle rigidity

70
Q

Murphy’s sign

A

And spiritually arrest gallbladder infection hold your finger under the liver border ask your patient to take a deep breath, not accurate for patients older than 60

71
Q

Iliopsoas muscle test

A

When appendicitis is suspected with the patient patient lies supine lift the right leg straight up and flex at the hip and then press down over the lower part of the right thigh The person is trying to hold their right leg up.

72
Q

Obturator test

A

The patient raises right leg flexing 90° at the knee while the examiner holds the ankle and rotates the leg internally and externally there should be no pain

73
Q

Considerations for all adults

A

Inspection - increase deposits of subcutaneous fat on abdomen and hips and abdominal masculature is thinner and has less tone

palpate - organs are easier to palpate and absence of obesity liver is easier to palpate or below coastal margin, kidney is easy to palpate.

74
Q

Developmental consideration for infants

A

Inspection-contour of abdomen because of immature abdominal musculature.

Peristalsis Visible because of the thin musculature

75
Q

Three types of joints

A

Synovial joints, non synovial joints, cartilage joints

76
Q

Ligament

A

Our fibereous bands running directly from one bone to another bone that strengthen the joint and help prevent movement in undesirable direction.

77
Q

Synovial joints versus non-synovial joints versus cartilage joints

A

Synovial joints contain synovial fluid, bursa fluid sacs and joints that are used to reduce friction.

Non synovial joints are minimal movement joints that provide integrity such as sutures of skull

cartilage joints are separated by fibrocartilage discs that are only slightly movable

78
Q

skeletal muscle movements range of motion

A 
Flexion or extension.
Abduction or adduction.
Pronation or supination.
Circumduction.
Inversion or eversion.
Rotation.
Protraction or retraction.
Elevation or depression.
79
Q

Muscle strength grading scale

A

5/5 full ROM against gravity, full resistance
4/5 full r o m against gravity, some resistance
3/5 full r o m against gravity, no resistance
2/5 full r o m without gravity, passive ROM
1/5 slight muscle contraction, no movement
0/5 absence of visible and palpable muscle contraction

80
Q

Ballottement

A

When large amounts of fluid are present compression on the Supra patellar pouch if no fluid then that means the patella is snugly against the femur

81
Q

Phalen

A

Ask the person to hold both hands back to back while flexing the wrist 90°

82
Q

Tinel

A

Direct percussion of the location of the median nerve at the risk producing no symptoms

83
Q

Muscle testing

A

Have patient flex and hold while you apply opposing force

84
Q

Developmental considerations for pregnant women

A

Increase level of circulating hormones cause increased movement and joints.

Lordosis curving inward lower back compensating for large fetus

85
Q

Aging adults musculoskeletal considerations

A 
Loss of bone matrix.
Postural changes.
The vertebral column shortens.
More pronounced bony prominences.
Absolute loss of muscle mass.

NURS 319 Health Assessment UMSON (4 decks)

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