Exam 2 Blueprint Flashcards
What is Stage 1 of a pressure ulcer?
Stage 1: skin is unbroken but inflamed; nonblanchable erythema of intact skin
AV valves - location and function
Tricuspid valve - between RA and RV
Mitral Valve - between LA and LV
What is Stage 4 of a pressure ulcer?
Stage 4: ulcer extends to muscle or bone; undermining is likely; exposed bone, tendon, or muscle
What are the focused questions for the lymphatic system?
- have you noticed any swollen glands or lumps?
– where are they located?
– how long have you had them?
– is the swelling continuous or occasional?
– what makes the swelling better or worse? - any recent changes in size?
- how do they feel to you: hard, soft?
- are any of the swollen glands associated with pain or local infection?
Normal breath sounds - description and location
B, BV, V
Bronchial: over trachea and large bronchi; tubular sound; high pitched hollow sounds
Bronchovesicular: medium-pitched sounds
Vesicular: inspiration louder and longer than expiration, low pitched sounds
Auscultation: Carotid Artery
How to do it
use the bell of stethoscope: better for higher grade stenosis
- place bell near upper end of thyroid cartilage, below angle of the jaw
have client take a breath, exhale, and hold briefly while you listen for <10 seconds
- listening for bruits
Arteries of arms and legs: pulse descriptions and grading of pulses
Grade force (amplitude) of pulse on a three-point scale:
0: absent
+1: diminished, weak, thready
+2: brisk, normal
+3: full, bounding
What is the acute wound classification?
Healing time: days to weeks
Edges well-approximated (can see are closing together)
Decreased risk of infection
Thorough healing process without delay
What is a deep tissue pressure injury?
Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration
What are ABCDE-EFG Lesions on Skin assessment
A - asymmetry
B - border
C - color
D - diameter
E - evolving
E - elevated
F - firm to palpation
G - growing progressively over several weeks
Palpation - cardiovascular assessment: Carotid artery
Info on carotid artery, how to palpate
carotid artery is a central artery
- palpate pulse, carotid upstroke, amplitude and contour, presence or absence of thrills
- timing closely coincides with ventricular systole (beginning of S1)
- located in groove between trachea and SCM muscle; medial to and along side it
provides information about cardiac function (aortic valve stenosis and regurgitation)
palpate bilaterally - avoid excessive pressure and palpate one at a time
**height of pulsations unchanged by position and not affected by inspiration
**
to palpate:
- patient should be supine with head of bed at 30 degrees
- inspect for visible pulsations - often just medial to SCM muscle
- index and middle fingers in lower third of neck and palpate
- want equal bilaterally, smooth contour, brisk
– decreased pulsations: decreased stroke volume from shock or MI and local atherosclerotic narrowing or occlusion
Focused questions to ask during respiratory assessment - continued
Smoking:
- packs per day (PPD)
- when did you start? cough with it? what kind?
Environment:
- work
- animals
- chemicals
Medications:
- some can cause a cough
- inhaler
Allergies:
- do you have any allergies?
- reactions to allergens?
Self-care behaviors?
- mask when cleaning? fragrances?
What is Stage 2 of a pressure ulcer?
Stage 2: skin is broken to epidermis or dermis; partial-thickness skin loss - shallow, open ulcer
Developmental Considerations for peripheral vascular assessment - pregnant women
edema: expect diffuse bilateral pitting edema in the LEs, especially at the end of the day and into the 3rd trimester
varicose veins: often seen in 3rd trimester
- veins are dilated and tortuous
- vein walls may feel somewhat thickened
Focused questions to ask during respiratory assessment for an aging adult
Have you noticed any SOB or fatigue with your daily activities?
Tell me about your usual amount of physical activity.
History of COPD, lung cancer, or TB
- how are you getting along each day?
- any weight change in the last 3 months? increase or decrease? how much?
How is your energy level? Do you tire more easily? How does your illness affect you at home and at work?
Do you have any chest pain with breathing?
Do you have any chest pain after a bout of coughing or after a fall?
Developmental considerations - cardiovascular assessment:
Infants and children: average heart rates
Years 1-2; Years 2-6; Years 6-10
Years: 1-2
– average rate: 110-120
– range: 88-155
Years: 2-6
– average rate: 100-110
– range: 65-140
Years: 6-10
– average rate: 75-90
– range: 52-130
Nail Assessment - integumentary system
Clubbing
Beau’s lines: transverse depressions that appear as white lines across the fingernails
– sign of acute severe illness; malnutrition
– or sign of systemic disease, trauma, or coronary occlusion
Splinter Hemorrhage: linear bleeding under a nail resembling a splinter
– seen after trauma and in bacterial endocarditis
Pitting: small punctate indentations in nails; often result of psoriasis
Pleural friction rub
What is it and sound
- inflammation of the lung tissues
- raspy breathing sound
Aging adult skin considerations
Elasticity - loses elasticity, skin folds and sags
Sweat and sebaceous glands - decrease in number and function; leaving skin dry
Skin breakdown due to multiple factors - cell replacement is slower; wound healing delayed
Senile purpura - discoloration due to increasing capillary fragility
Hair matrix - functioning melanocytes decrease, leaning to gray fine hair
Keratoses - raised thickened area of pigmentation, crusty or warty in appearance
Skin tags - overgrowth of skin with a stalk
Auscultation: Heart sounds - where to listen
Identify auscultatory areas: four traditional valve areas and Erb’s point
– valve areas are not over actual anatomic locations on valves but sites on chest wall where sounds are best heard
sound radiates with blood flow direction
“All people eat taco meat”
aortic valve area: 2nd right ICS; S2
pulmonic valve area: 2nd left ICS; S2
Erb’s point: 3rd left ICS; S1=S2
tricuspid valve area: 4th left ICS; S1
mitral valve area: 5th left ICS @ MCL; S1
Structure and more functions of the skin
Epidermis: outer highly differentiated layer
– Basal cell layer forms new skin cells - contains keratin
— melanocytes: derivation of skin color
– Outer horny cell layer of dead keratinized cells (outer layer)
— replaced every 4 weeks
Dermis: inner supportive layer
– connective tissue (collagen)
– elastic tissue
Subcutaneous: adipose tissue
Focused questions for cardiovascular - continued
- chest pain: do you have any chest pain or chest discomfort
- dyspnea: any shortness of breath?
- orthopnea: how many pillows do you sleep with? comfort or breathing?
- cough: when does it occur?
- edema: in feet or legs? socks/shoes tight?
- syncope: any LOC or dizzy getting up?
- nocturia: getting up to pee at night?
- cyanosis: changes in lips or fingertip color - blue?
What is the chronic wound classification?
Do not move through normal sequence of repair (remains in inflammatory phase)
Edges often not approximated (not closing or connected)
Increased risk of infection
Healing time delayed
What are complications of wounds
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation