Final Blueprint Flashcards
Respiratory assessment: focused questions
Shortness of breath (SOB) or dyspnea:
- Have you had any difficulty breathing?
- Rest, exertion, how much exertion
- Supine (orthopnea) or at night (paroxysmal nocturnal dyspnea), relieved by sitting
Cough:
- what brings on a cough?
- Hemoptysis: do you cough up blood?
– what does it look like, what brings it on, when did it start, quantity?
- do you have any allergies? What kind and what happens?
Chest pain (CP) with breathing:
- do you have any chest pain or chest discomfort?
Respiratory infection:
- have you had any respiratory infections? often?
Ears: otitis media
- infected fluid in the middle ear
- eardrum looks red and swollen
- can close off Eustachian tube
Phases of wound healing
I just added more info because I wanted to know what it was
- Stage 1: hemostasis
**- The immediate phase that begins the wound healing process- blood clot forms to prevent further blood loss. - Stage 2: inflammatory- immune cells recruited to the area
- Stage 3: proliferation*The wound contracts and new blood vessels are built to support the growth of new tissue.
- Stage 4: maturation aka: remodeling
**The wound completely closes and the new tissue develops strength and flexibility. can take up to a year.
PVD vs PAD
PAD is a specific type of PVD (PVD is umbrella)
Peripheral vascular assessment: focused questions
- chief complaint present illness
- do you have any leg pain or cramps?
- have you noticed any skin changes on your arms or legs?
- have you noticed any swelling/edema anywhere on your body?
- have you noticed any swelling/enlargement of your lymph nodes?
- medications: current and past, and reason
- smoking: PPD
Function of the respiratory system (5)
- supplies oxygen to the body
- eliminates carbon dioxide
- maintain homeostasis
- maintain heat exchange
- alveoli: exchange of oxygen and carbon dioxide
Oxygenation Depends on
What systems
- Airway system to transport air to and from lungs
- Alveolar system to exchange oxygen and carbon dioxide
- Cardiovascular system and blood supply to carry nutrients and wastes to and from body cells
Review of systems: focused questions
Why do we ask focused questions
targeted problems
Skin cancer: culture and genetics
Risk factors, Men V women, dark vs light skin
- genetic attributes of dark-skinned individuals afford protection against skin cancer due to melanin
- increased likelihood in caucasians compared to hispanic and african american populations
- women <50 at higher risk for melanoma
– at 65, men double the rate of women; tripled by 80 - risk factors:
– high exposure to UV radiation
– family history of melanoma
– atypical or high number (>50) moles
– increased risk for easy burners and natural blond/red hair - 95% of melanoma caused by UV radiation exposure
Data collection: objective data
- what the nurse observes: physical exam
- lab and diagnostic testing
- signs
Neurological assessment: abnormal findings for movement and muscle tone
Muscle Tone
- Flaccidity
- Spasticity
- Rigidity
- Cogwheel rigidity (watch-hand arm ticking)
Movement
- Paresis
- Paralysis
- Myoclonus (hiccups/epilepsy)
-** Fasciculation/Tic/Tremor
– Resting
– Intention
– Chorea (parkinsons)
– Athetoid (cerebral palsy)
Atrioventricular (AV) valves: location and function, when they open and close relating to cardiac cycle
Tricuspid valve - between RA and RV
Mitral Valve - between LA and LV
During systole - the AV valves are closed as this is pumping phase - prevents blood from backing into the aorta (regurgitation)
During diastole - the AV valves are open, filling phase as ventricles fill with blood
Respiratory assessment: developmental considerations (pregnancy)
- Diaphragm elevated 4cm
- Decreased vertical diameter thoracic cage
- Increased horizontal diameter, increased tidal volume
What is the Ankle-Brachial Index
it assesses for peripheral arterial disease (PAD); is the ratio of BP measurements in the foot and arm
- two measurements taken and then average is used as the recorded pressure
ABI = (systolic ankle pressure)/(highest systolic brachial pressure)
What happens during..Systole (AV)
valves are closed, pumping phase-prevents blood
from backing into the aorta (regurgitation)
Ears: inspection and palpation
- auricle
- tragus
- lobes
- external ear canal
– inspect piercings: healed, infections, keloids
palpate external ear
Testing cerebellar function (4)
Test through normal ROM
Testing cerebellar function
- finger to nose
- standing posture
- heel to shin
- gait pace
Assessing balance and gait/coordination
Romberg test- make sure they dont fall (Stand still for 30 seconds and not lose balance)
Finger-to-nose test
Heel to shin- to test for neurological vs weakness
Rapid alternating movements - flip hands back and forth (how fast pt can do it)
Respiratory assessment: palpation - tactile fremitus (findings: increased, decreased, crepitus, what to assess)
Decreased/absent: voice is higher pitched or soft
- something obstructs the transmission of vibration
- COPD, pleural effusion, fibrosis, pneumothorax, infiltrating tumor, emphysema
Increased:
- compression or consolidation of lung tissue
- lobar pneumonia
Crepitus:
- coarse, crackling over skin surface
- subQ emphysema (when air is in tissue and can feel it; can happen with chest tubes)
Assess:
- temperature
- lesions
- masses
- wounds
how to do it
assess for symmetry
use ball or ulnar surface of hand
ask patient to repeat words “99” or “one one one”
initially used for side-by-side comparison
both hands to palpate and compare symmetry
identify and locate any areas of increased, decreased or absent fremitus
for women: gently displace the breasts anteriorly
anteriorly: fremitus is usually decreased or absent over the precordium
Cranial Nerve 11: function and assessment
Spinal accessory
Motor
- Trapezius and sternomastoid movement
– have patient turn head and apply resistance
– assess shoulder shrug
Verbal communication
appropriate verbal communication:
- simple, recognizable and clear words
- use non-stigmatizing language; don’t them to shut down
Stridor
- high-frequency, high-pitched musical sound produced during airflow through a narrowing in the upper respiratory tract
- obstruction - foreign body
What is anosmia
loss of sense of smell
Cardiovascular assessment: palpation of the PMI (apical pulse)
represents the brief early pulsation of the LV as it moves anteriorly during systole and makes contact with the chest wall
palpable in about half of adults; not in those obese or with thick chest walls
– displaced to the left in heart failure
– if can’t find: ask person to exhale and hold; ask patient to roll partly onto left side
high cardiac output:
- apical impulse increase in amplitude and duration
- anxiety, fever, hyperthyroidism, anemia
Edema grading 1+
Barely detectable impression when finger is pressed into skin. May have mild pitting, slight indent, no perceptible swelling of legs