Final Flashcards
medical dx
only made by doctors
nursing dx
used to evaluate the response of the whole person to actual or potential health problems
nursing process
- iterative process allowing practitioners to move back and forth while caring for the needs of complex pts.
- Includes six phases: assessment, diagnosis, outcome identification, planning, implementation, evaluation
“A Delicious Orange PIE”
Assessment- collect data
Diagnosis- interpret data
Outcome identification- identify the expected outcomes
Planning
Implementation- doing what you planned
Evaluation- was the outcome we wanted achieved?
inspection phase
concentrated watching. Checking for abnormalities before continuing. Inspection begins the moment you first meet a person and develop a “general survey”
purpose of percussion
- mapping out the location and size of an organ by exploring where the percussion note changes b/n the borders of an organ and its neighbors
- signaling the density (air, fluid, or solid) of a structure by a characteristic note
- detecting an abnormal mass if its fairly superficial; the percussion vibrations penetrate a/b 5 cm deep—a deeper mass would give no change in percussion
- eliciting a deep tendon reflex using the percussion hammer
diaphragm
used for high-pitched sounds → breath, bowel, and normal heart sounds. Hold the diaphragm firmly a/g the person’s skin, firm enough to leave a slight ring afterwards
bell
used for soft,low-pitched sounds such as extra heart sounds or murmurs. Hold it lightly a/g the person’s skin, just enough that it forms a perfect seal
1st level priorities
emergent, life threatening
airway, breathing, circulation, vital signs
2nd level priorities
requires prompt intervention to forestall further deterioration
acute pain, mental status change, abnormal labs, risk of infection
3rd level priorities
those that are important to the pt’s health but can be addressed after more urgent problems. Interventions to treat these problems are more long term, and the response to treatment is expected to take more time
subjective data
what the pt says, biased
objective data
unbiased, what the pt cannot see, labs
how do you prioritize patient problems/diagnosis?
airway → breathing → circulation → perfusion
spirituality
broader term focused on a connection to something larger than oneself and a belief in transcendence
religion
organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services
role of nurse with DM
for neglect in the elderly and children, report your suspicions to the proper authorities. No evidence is needed, when in doubt, REPORT
BMI
weight (lbs.) / height (in.) * 703
- normal = 18.5-24.9
- <18.8 → underweight
- want to be less than 25 > 30 = obese
negative effects on elderly nutritional status
lack of taste, medications, teeth issues, decreased GI motility, decrease visual acuity, decreased saliva production
how long would you monitor a heart rate if it is irregular
1 full minute
proper way to take a BP
palpate pulse in radial artery,
Let air out 2-4 mmHg/second.
Listen for first and last sounds, Pt shouldn’t cross legs, chew gum, drink caffeine, etc in the past 30 minutes or smoked in the past 5 minutes.
best indicator of pain
pt report of pain, subjective data
systolic number (top #)
indicates how much pressure your blood is exerting a/g your artery walls when the heart beats
diastolic number (bottom #)
indicates how much pressure your blood is exerting a/g your artery walls while the heart is resting b/n beats
uvula
rises on phonation, midline to soft palate, CN 9 (glossopharyngeal)
frenulum
midline fold of tissue that connects the tongue to the floor of the mouth
strabismus
a disorder in which the eyes don’t look in the same direction at the same time; “cross eyed”
anisocoria
condition characterized by an unequal size of the eye’s pupils
tympanic membrane, normal findings on internal ear exam:
separates outer and middle ear; pearly grey in color, prominent cone of light, drum is oval and slightly concave
external ear
auricle or pinna
consists movable cartilage and skin
middle ear
- chamber between the eardrum and cochlea
- contains auditory ossicles: the malleus, incus, and stapes.
- Functions: vibrations, protection by reducing sounds, equalization of air pressure, conducts sound waves from external ear to internal ear
inner ear
Inner Ear
contains the bony labyrinth
holds the sensory organs for equilibrium and hearing.
Not visible but function can be tested
examination considerations for a child
the infant’s eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult’s; thus it is easier for pathogens from the nasopharynx to migrate through to the middle ear. These factors place the infant at greater risk for middle ear infections than the adults. The infant and the young child’s external ear canals are shorter and have a slope opposite to that of the adult’s
cerumen
- yellow, waxy material that lubricates and protects the ear
- wet, honey-brown wax → occurs in Caucasians and AA
- dry, flaky white wax → occurs in East Asians and Native Americans
Peau d’Orange
Breast tissue: edema exaggerates the hair follicles, giving a “pigskin” or “orange-peel” look
when is a breast mass suspicious of cancer during an exam
solitary, unilateral, nontender mass. Single focus in one area, although it may be interspersed w/ other nodules.
Solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Borders are irregular and poorly delineated. Grows constantly. Often painless, although the person may have pain. Most common in upper outer quadrant. Firm and hard irregular axillary nodes as cancer advances; skin dimpling, nipple retraction, elevation and discharge
Know blood flow through the heart
inferior/superior vena cava → RA → tricuspid valve/semilunar → RV → pulmonic valve → pulmonary artery → lungs → pulmonary vein → LA → mitral valve → LV → aortic valve → aorta → body
orthopnea
difficulty of breathing when laying down
the need to be upright position to breath. *note # of pillows used
Paroxysmal nocturnal dyspnea
awakening from sleep w/ SOB. Pt wakes up after 1-2 hours of sleep w/ the perception of needing fresh air (drowning syndrome)
aortic aneurysm
unilateral distention of external jugular veins (JVD); murmur is harsh, systolic, or continuous and accented w/ systole.
Marked pulsations/prominent lateral pulsations can indicate aortic aneurysm
orthostatic hypotension
sudden drop in systole more than 20 mmHg or diastole more than 10 mmHg, in BP when rising to sit or stand
iliopsoas
- supine, lift right leg straight up, flexing at the hip, push down over lower part of thigh as person tries to hold leg up.
- negative = pt feels no pain
- positive = pt feels pain; pain in RLQ is indicative of appendicitis
obturator
lift right leg, flexing at the hip, and 90 degrees at the knee. Hold pt ankle and rotate leg internally and externally. There should be no pain; less specific than iliopsoas test but could indicate appendicitis as well
Murphy’s tests
Check gallbladder/cholestasis. Ask pt to take a deep breath while palpating the right subcostal area.
Inflammation of the gallbladder will result in pain (positive sign)
blumberg’s sign
“rebound tenderness”
indicative to peritonitis
positive = pain on release
borborygmi
loud, gurgling sounds;
increased motility
early mechanical bowel obstruction (high-pitched)
gastroenteritis, brisk diarrhea, laxative used
subsiding paralytic ileus
upper GI bleeding
black, tarry stool due to occult blood
vomiting blood or coffee grounds
lower GI bleeding
bright red blood in stool
dark blood mixed with stool
how do you assess the mental status?
ABCT
appearance (posture, dress, grooming, hygiene) behavior (LOC, facial expression, speech, mood) cognitive function (judgement, recent and remote memory)
thought process (thought content/perception)
flat affect
lack of emotional response; no expression of feeling, voice is monotone and face immobile
epispadias
- dorsal location of meatus; meatus opens on the dorsal (upper) side of the glans penis
- less common that hypospadias but more disabling b/c of associated urinary incontinence and separation of the pubic bones
hypospadia
ventral location of meatus; urethral opens on the ventral (under) side of the glans or shaft or at the penoscrotal junction. A groove extends from the meatus to the normal location at the tip. This congenital defect is important to recognize at birth. The newborn should not be circumcised b/c surgical correction may need to use foreskin tissue to extend urethral length
testicular torsion
- spermatic cord get twisted and cuts off blood flow to testicles. Often during sleep or following trauma
- S&S: sudden onset excruciating pain in testicle, N/V, NO fever
- obj. findings- red, swollen, one testes (usually left) is higher due to rotation and shortening
epididymitis
- acute infection of epididymis commonly caused by prostatitis, after prostatectomy b/c of trauma, or chlamydia, gonorrhea, or other bacterial infections
- subjective: severe pain in scrotum, relieved by elevation (+ Prenn sign) elevation of testes causing pain relief, rapid swelling, fever
priapism
- prolonged painful erection w/o sexual stimulation. Unrelieved by intercourse or masturbation. most common in 30s-40s; rare.
- ischemia can happen in 4h. Medical emergency b/c necrotic fast
- SE of some meds: street drugs, sickle cell, leukemia, malignancy, local trauma, spinal cord injury w/ ANS dysfunction
know where sperm production occurs
seminiferous tubules
Gonorrhea
Vaginal discharge, dysuria, abnormal bleeding, abscess in Bartholin or Skene glands
often no signs are apparent.
Dx by positive culture of organism.
Treat w/ antibiotics and retest in 3-6 months
Candidiasis
intense pruritus; discharge is usually white, thick, curdy, “like cottage cheese;”
vulva and vagina are erythematous and edematous
causes are recent use if antibiotics, wearing tight underwear, douching, diabetes (undiagnosed)
Chlamydia
minimal or no symptoms
yellow/green discharge
untreated leads to PID and sterility
pap smears, screen for what?
cervical cancer
Chadwick’s sign
cyanotic (blue) appearance of vagina. Mucosa and cervix; during 2nd trimester (8-12 wks)
normal weight gain
25-35 lbs in a singleton pregnancy of a woman with a normal BMI
overweight weight gain
28-40 lbs
underweight weight gain
15-25 lbs
BMI of pregnant women
19-25
estimating delivery date
280 days from the last menstrual period
Angle of Louis
sternal angle, good clinical anatomical location; 2nd rib
normal mechanism of respirations
relaxed, regular, automatic and silent
check if pt is using accessory muscles to breath (abnormal)
atelectasis
complete or partial collapse of a lung or section (lobe) of a lung (airway obstruction, compression on lung, lack of surfactant)
mediastinum
middle section of the thoracis cavity containing the esophagus, trachea, heart, and great vessels
The right and left pleural cavities on either side of the mediastinum contain the lungs
APGR
newborn’s first respiratory assessment scored 1-5 minutes after birth
- 0-2: severely depressed newborn needing full resuscitation, ventilatory assistance, and subsequent intensive care
- 3-6: indicates a moderately depressed newborn needing more resuscitation and subsequent close observation
- 7-10: newborn in good condition, needing only suctioning of the nose and mouth and otherwise routine care
Principles of Prioritization
- complete health history, including allergies, medications, current medical problems, reason for visit
- Determine if problems are related and set priorities
- Priority setting will evolve over time, address accordingly
sources of pain
- visceral- large internal organs
- somatic- surface musculoskeletal
- deep somatic- blood vessels, joints, tendons, muscle, bone
- cutaneous- skin surface, subcutaneous tissue
- referred- felt in one place but comes from another
acute pain
short-term, self-limiting, often predictable trajectory; stops after injury heals
chronic pain
episode of pain that lasts for 6 months or longer; may be intermittent or continuous
nociceptive pain
pain from a normal process that results in noxious stimuli being perceived as painful
neuropathic pain
abnormal processing of pain message; pain from a lesion or disease in the somatosensory nervous system
CN 1 Olfactory
Abnormal:
ansomia (loss of smell)
head trauma, brain lesion
CN 2 Optic
Abnormal:
visual field loss
papilledema (increase ICP)
optic atrophy
CN 3, 4, 6
oculomotor, trochlear, abducens
Ptosis (myasthenia gravis) Horner syndrome, Cushing Reflex (increased ICP), unequal pupil dilation, non reactive pupil, nystagmus (vestibular, cerebellum or brainstem disease)
CN 5 Trigeminal
Abnormal:
unilateral weakness (lesion on pons or cancer)
decreased or uneaqual sensation (stroke, hemiparesis, aphasia)
CN 7 Facial
Abnormal:
muscle weakness flat nasolabial fold, drooping face, air escapes one side (stroke), upper and lower affected on one side is Bell’s Palsy
CN 8 Acustic/Vestibulocochlear
Abnormal:
hearing acuity decrease, unable to detect high-frequency sounds (whispers); conductive hearing loss
CN 9 Glossopharyngeal
CN 10 Vagus
Abnormal:
absence or asymmetry of soft palate, risk for aspiration (stroke), hoarse or brassy voice (vocal cord dysfunction)
CN 11 Spinal Accessory
Abnormal:
Atrophy, muscle weakness
paralysis after stroke
peripheral nerve damage
CN 12
Atrophy, Fasciculations, tongue deviates to paralyzed side after stroke
Motor System evaluation
Abnormal:
LMN disease, disuse, injury
paresis (weakness, decreased strength)
paralysis/plegia (absence of strength)
hypertrophy (increased muscle size)
limited ROM
Flaccidity (decreased resistance)
hypertonia
spacity and regidity with central weakness
Cerebellar Function evaluation
Abnormal:
lack of coordination
slow, clumsy, sloppy response
dysdiadochokinesia (w/ cerebellar disease)
Dysmetria or drunkeness
Balance Test Evaluation
Abnormal:
stiff immediate posture, staggering, widened gait
lack of swaying arms
ataxia, uncoordinated/unsteady gait
tandum walk: in ability due to upper motorneuron lesion, MS, drunkeness, acute cerebellar dysfunction
Romberg Positive = loss of proprioception
decrease in vestibular function
Sensory Evaluation
sharp/dull Abnormal:
hypoalgesia (decreased pain sensation)
analgesia (absence of pain sensation)
hyperalgesia (increased pain sensation)
Deep Tendon Reflex Evaluation
Abnormal:
Clonus: rapid, rhythmic contractions of same muscle
Hyperreflexia: exaggerated reflex (stroke)
Hyporeflexia: absense of reflex (spinal cord injury)
resonant
clear, hollow (lungs)
Hyperresonance
lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax (lungs)
tympany
high-pitched, musical, drum like percussion note heard when percussing over the stomach and intestine
dull
muffled thud, dense organs; liver, spleen
flat
dead stop of sound; thighs, bones, tumor
mobility and turgor
mobilty the skin’s ease of rising, and turgor ability to return to place promptly when released normally < 3sec, reflects elasticity of skin
dehydration
dry mucous membrane, dry lips, tenting skin
Edema 4-point Scale
1+ mild pitting; slight indentation, no perceptible swelling of the leg
2+ moderate pitting; indentation subsides rapidly
3+ deep pitting; indentation remains for a short time; leg is very swollen
4+ very deep pitting; indentation lasts a long time; leg is very swollen
vellus hair
pale, fine body hair of children and adult females
terminal hair
coarse, long hair of eyebrows, scalp, axillary, and pubic regions
profile sign in nails
should be less 160 degrees, smooth, pink, capillary refill <3 seconds
Head
normocyphalic- average; normal
macrocephalic- larger than normal
microcephalic- smaller than normal
Stroke vs Bell’s Palsy
Stroke: signs of mental cloudiness, confusion
Bell’s Palsy: normal mental function
Teeth
normal adult mouth 28 teeth 32 with wisdom teeth
hard palate
anterior, white
soft palate
posterior, pink, moist
Tonsils graded in size as follows:
1+ visible
2+ halfway between tonsillar pillars and uvula
3+ touching the uvula
4+ touching each other; “kissing”
limbus
border between cornea and sclera
lacrimal gland
gland located in the upper outer region above the eyeball that secretes tears
palpebral conjunctiva
covers the inner surface of the eyelids
bulbar conjunctiva
overlays the eyeball, with the white sclera showing through
cultural taboos
no vaccines
blood transfusions
obstain from medications with caffeine, pork, other prohibited substances
Symptom or Sign
symptom: subjective
sign: objective
Nosocomial infections are
hospital acquired infections
Normal pulse is
60-100 bpm
4 functions of respiratory system
- supplies oxygen for energy production
- removes CO2
- maintains homeostasis of arterial blood
- maintains heat exchange, stabilized body temperature
involuntary control of respirations
pons and medulla (brainstem)
bronchial
over trachea and larynx
high-pitched
loud
anterior only
heard less on inspiration than expiration
bronchovescicular
over major bronchi
moderate pitch/amplitude
anterior and posterior
heard the same on inspiration and expiration
vescicular
peripheral lung fields
low pitch
soft
anterior and posterior
heard greater on inspiration than expiration
adventitious breath sounds
crackles (rales)- popping
wheeze (rhonchi) - high pitch squeeking
pleural friction rub - coarse, low-pitched grading
stridor- high-pitched crowing sound
Tachypnea
rapid breathing
bradypnea
abnormally slow breathing
Hyperventilation
the condition of taking abnormally fast, deep breaths
Kussmual respirations
Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.
Cheyne-Stokes respiration
repeated breathing pattern characterized by fluctuation in the depth of respiration: first deeply, then shallow, then not at all
S1
loudest at the apex
represents the closure of the AV valves (tricuspid & mitral)
begins systole
is the LUB sound
S2
loudest at the base
represents th closure of the semilunar valves (pulmonary & aortic)
begins diastole
is the DUB sound
Bruit
abnormal blowing or swishing sound heard during auscultation of an artery or organ
heave
forceful thrusting of the ventrcile during systole; seen at the apex
thrill
palpable vibration on the chest wall accompanying severe heart murmur
arterial blood
moves forward by the pressure of the pumping of the heart
moves away from the heart
venous blood
moves forward by the contraction of skeletal muscles and has a one-way valve that does not allow blood to flow backwards;
moves towards the heart
grade pulses
4+ (bounding)
3+ (full/increased; may be normal)
2+ (normal)
1+ (weak, barely palpable)
0 (absent)
claudication
pain caused by too little blood flow to muscles during exercise
barrel chest
a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.
Glascow Coma Scale (GCS)
Neurologic assessment of a patient’s best verbal response, eye opening, and motor function
lowest is 3, highest is 15
eye 1-4
motor 1-6
verbal 1-5
a score of less than 7 is coma
Sequence of abdominal assessment
Inspect, Auscultate, Percuss, Palpate
contours of the abdomen
- flat
- scaphoid- abdominal wall is sunken & presents a concave rather than convex contour
- rounded
- protuberant- unusual convexity caused by poor muscle tone or excessive subcutaneous fat
normal bowel sounds
5-30 per minute
costovertebral tenderness
***often associated w/ RENAL DISEASE
- warn pt what you’re about to do
- have pt sit up on exam table
- use heel of closed fist to strike pt firmly over costovertebral angles
- compare left and right sides
no bowel sounds
must listen for a total of 5 minutes in the RLQ
ROM scale
5 - full ROM against gravity, no resistance
4 - full ROM against gravity, slight resistance
3- Full ROM with gravity
2 - slight contraction
1 - no contraction
3 things that influence temperature
time of day
diurnal cycle
exercise
age
3 causes of tachycardia
fever
sepsis
pneumonia
pulse pressure
difference between systolic and diastolic pressure
Korotkoff sounds
sounds heard while taking the blood pressure
Babinski reflex (sign) positive
a reflex action, fanning of the toes; in adults is indicative of abnormalities in the motor control pathways leading from the cerebral cortex
