Final Exam Flashcards
Subjective Data
what the pt tells you
objective data
information that the nurse gathers about a pt
ex. vital signs
primary data
client is the primary source of data
secondary data
another healthcare provider, family, other support persons, records and reports, etc are the primary sources of data
primary subjective
what pt says
secondary subjective
family member
primary objective
your findings
secondary objective
another nurses (or healthcare providers) findings
What are the components of general survey?
physical appearance, body structure, mobility, behavior
Complete Assessment
complete history and head-to-toe assessment
ex. assessment on admission
Focused Assessment
more focus on 1 system
ex. skin, cardiac, respiratory
Follow Up Assessment
rapid collection of crucial info
ex. pt comes into ED and the nurse gets a history from the family in order to take care of an emergent situation
Inspection
ALWAYS DONE FIRST, done by using sight to gather data, can be used throughout the physical examination, different tools can be used to enhance inspection
Palpation
make sure hands are warm, start light to deep, palpate tender areas last
Percussion
Flatness- bone or muscle
Dullness- liver, spleen
Resonance- air-filled, i.e lungs(hollow)
Hyperresonance- emphysematous lung
Tympany- air-filled stomach
Auscultation
the act of listening to sound produced by the body with an assistive device
ex. listening to bowel sounds through stethoscope
Gender Role
the role or behavior learned by a person as appropriate to their gender, determined by the prevailing cultural norms
Gender
The sex a person is assigned at birth
Gender Identity
The gender that a person identifies with
Pressure Injury Stage 1
no break in skin
Pressure Injury Stage 2
abrasion, blistering, crater
stage 3 pressure injury
skin breakage through epidermis, dermis, and into subcutaneous
stage 4 pressure injury
subcutaneous skin breakage, damage to bone, muscle, tendons, sloughing, and escar
unstageable pressure injury
escar, sloughing, cannot stage until the wound is cleaned, but you can assess how deep it is
Deep Tissue Injury
skin is intact, deep, purplish, may be covered with escar, feels squishy
pressure injury prevention
- inspect the skin daily
- manage moisture (dry the skin after wiping, incontinence care)
- skin care (keeping skin clean with mild soaps)
- minimize pressure (reposition every 2 hours, elevate heels)
- avoid friction to the skin (utilize TAPS)
- optimize nutrition and hydration (good nutrition helps to heal wounds)
ABCDE
asymmetry (within borders)
border (irregularity)
color (black, variations)
diameter (> 1/4)
evolution (is it getting bigger?)
primary lesions
- appear as a direct result of the disease
- occur at the onset of the disease
- macule-petechiae, measles, freckles
secondary lesions
- may develop from primary lesions or result from external trauma
ex. scratching, infections - scales, crusts, ulcers
- may occur if the primary lesion does not heal
Assessing Hair
- ask if pt colors their hair
- texture (course, curly, smooth, straight, knotty)
- distribution (even, sparse)
- scalp (should be smooth, non tender, and freely moveable)
-pediculosis (should be free of head lice)
Assessing Nails
color- should be pink
shape- should be convex
texture- should be smooth, no ridges
assess capillary refill- should be < 3 seconds
assess for clubbing- nail angle should be about 160°, clubbing = angle > 180°
What are pale nails a sign of?
cold, cyanosis
What are black nails a sign of?
trauma
What is the correct order of blood through through the cardiac valves?
Tricuspid, Pulmonic, Mitral, Aortic
Where are the tricuspid and pulmonic valves located?
on the right side of the heart, they flow blood to the body
Where are the mitral and aortic valves located?
on the left side of the heart, they flow blood to the lungs
What is S1 and where is it heard the loudest?
closing of the mitral and tricuspid valves (lub), loudest at the apex
What is S2 and where is it heard the loudest?
closing of the pulmonic and aortic valves, loudest at the base
Right Sided Heart Failure Characteristics
- right chamber has lost the ability to pump
- fatigue
- high peripheral venous pressure
- Ascites
- Enlarged liver and spleen
- weight gain
- may be secondary to chronic pulmonary problems
- distended jugular veins
- anorexia and complaints of GI distress
- dependent edema (swelling when legs are down)
Left Sided Heart Failure Characteristics
- blood received from lungs loses ability to contract
- Paroxysmal nocturnal dyspnea
(SOB at night, typically when lying down) - elevated capillary wedge pressure
- pulmonary congestion (cough, crackles, wheezes, blood tinges sputum, tachypnea)
- restlessness
- confusion (O2 saturation comprimised)
- orthopnea
- tachycardia
- exertional dyspnea
- cyanosis (decreased O2)
Cardiovascular assessment: normal vs. abnormal findings
- Assessment of carotid artery- should not be able to be seen
abnormal = bulging
auscultate for bruit and venous hum - Assessment of jugular vein- assess supine at 45° angle, assess for fullness and pulsations (abnormal)
- Assessment of precordium- no pulsations should be visible except for at the PMI, should not see any heave or lift
- Auscultation- should not hear murmurs
Peripheral Vascular Developmental Considerations for Pregnant Women
- Blood pressure decreases because of hormonal changes, peripheral vessels dilate
- lower extremity edema and varicosities in legs because of enlarged veins
Peripheral Vascular Developmental Considerations for Older Adults
- increase in systolic BP
- blood vessels become rigid
- arteries calcify (arteriosclerosis, stenosis)
- arterial walls lose elasticity and vasomotor tone
- superficial vessels become more prominent (varicosities)
- increased peripheral vascular resistance
- decreased venous return (orthostatic BP changes)
Lymphedema Assessment and Interventions
- caused by removed lymph nodes, breast cancer
- radiation can destroy lymph nodes
- prevent with compression hose, physical activity, and massage
Arterial Ulcer vs. Venous Ulcer
Arterial:
- deep, crusty nails
Venous:
- border always irregular
Where do arteries take blood?
away from the heart
Where do veins take blood?
to the heart
Characteristics of Peripheral Venous Disease
- normal skin temp
- increased edema
- dry and flaky skin with brownish discoloration
- hair present
- leg elevation lessens pain
- wounds occur secondary to inadequate functions of system
- wounds are initially superficial, irregular in shape
- wounds are proximal to the medial malleolus
- pedal pulses normal
- nails are normal
- pain is mild to moderate
- pain increases at the end of the day as edema increases
Characteristics of Peripheral Arterial Disease
- skin temp decreased
- normal edema
- tissue thin and shiny
- hair loss
- leg elevation increases pain, dangling decreases pain
- wounds due to ischemia from lack of oxygenated blood
- wounds lack granulation tissue, smooth edges that are well defined
- ulcers on lateral malleolus, lower third of leg, toes, web spaces
- pedal pulses diminished
- yellow thickened nails
- severe pain
- pain with walking, relieved with rest
Where are bronchial sounds located?
over the body of the sternum
Where are bronchovesicular sounds located?
between the first and second intercostal spaces of the anterior chest
Where are vesicular sounds located?
below the second rib at the base of the lungs
Normal vs. Abnormal Inspection of the Lungs
Normal:
- no use of accessory muscles
- no nasal flare
- respirations 12-20
- relaxed position
- relaxed facial expression
Abnormal:
- retraction
- use of accessory muscles
- barrel chest
- pectus excavatum/carinatum
- scoliosis, kyphosis
What is the AP: Lateral ratio?
1:2
Name some abnormal respiration patterns
sigh, tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes, Biot’s
Normal vs. Abnormal Palpation of the lungs
Normal:
- symmetric chest expansion
- tactile fremitus
Abnormal:
- crepitus
- pain
Normal vs. Abnormal Palpation of the lungs
Normal:
- symmetric chest expansion
- tactile fremitus (equal vibration on both sides)
Abnormal:
- crepitus
- pain
Normal vs. Abnormal Lung Auscultation
Normal:
- clear
Abnormal:
- crackles: course and fine
- wheezes
- stridor
- pleural friction rub
What order should bowel sounds be assessed in?
RLQ, RUQ, LUQ, LLQ
What position should the patient be in for an abdominal assessment?
supine with legs bent to reduce tension
What is the sequence of an abdominal assessment?
inspection, auscultation, percussion, palpation
What are the normal and abnormal abdomen contours?
Normal: flat and rounded
Abnormal: scaphoid and protuberant
What are some abnormal abdominal findings?
- umbilical, epigastric, and incisional hernias
- diastasis recti
- abdominal distention (obesity, air/gas, ascites, ovarian cyst, pregnancy, feces, tumor)
hypoactive bowel sounds
<5 bowel sounds per minute
hyperactive bowel sounds
> 30 sounds per minute
normoactive bowel sounds
5-30 sounds per minute
What is the expected finding of percussing the costovertebral angle?
no costovertebral angle tenderness
What are abnormal findings of percussion of the costovertebral angle?
- pain or tenderness
- kidney infection
- musculoskeletal problems
Rebound Tenderness/Blumberg Sign
- symptom of appendicitis
- tests for peritoneal irritation
- warn the patient before beginning
- press deeply on the abdomen, then after a moment, quickly release pressure. If it hurts more upon release, the patient has rebound tenderness
Normal Stool Findings
- brown
- soft consistency
- Newborn- meconium
Abnormal Stool Findings
- black tarry
- red
- clay (lack of bile/blocked bile duct)
- yellow or greasy
- diarrhea
- constipation
- fecal impaction (leaking stool)
- pinworms
Female GU Assessment
External inspection-
- skin color
- hair distribution
- labia majora
- lesions
- clitoris
- labia minora
- urethral opening
- vaginal opening
- perineum
- anus
What are the axillary nodes called?
central, pectoral, subscapular, lateral
Male GU Assessment
Penis:
- inspect skin for lesions
- discharge
- pubic hair pattern, infestation
Scrotum
- Skin
- any mass or lumps
Perianal Area
- skin
- anal opening
Testicular Exam
should be no masses, pain
Female Breast Exam
- Inspect general appearance
- skin
- lymphatic drainage areas
- nipple
- maneuvers to screen for retraction
- axillae
- should be no masses, pain
Muscle strength 5/5
full ROM against gravity, full resistance
muscle strength 4/5
full ROM against gravity, some resistance
muscle strength 3/5
full ROM with gravity
muscle strength 2/5
full ROM with gravity eliminated (Passive motion)
muscle strength 1/5
slight contraction
muscle strength 0/5
no contraction
What are some developmental considerations about an infant’s spine?
- C shaped
- observe for tuft of hair or dimple
- spina bifida
What are some developmental considerations for a toddler, preschooler, or school age child, for the musculoskeletal system?
- lordosis
- genu varum(bow legged)
- genu valgum(knock knees)
- pes planus(flat feet)
- pigeon toes
- subluxation(nurse maids elbow)
What are some developmental considerations about adolescents for the musculoskeletal system?
- sports injuries
- tech neck
- scoliosis
- kyphosis
What are some developmental considerations about pregnant women for the musculoskeletal system?
- lordosis
- forward cervical flexion
- waddling
What are some developmental considerations about aging adults for the musculoskeletal system?
- decrease in height
- shortening of trunk
- dorsal kyphosis
- base of support broader
- reduction in total muscle mass
- decrease in fat in periphery, more in hips/abdomen
How to assess cranial nerve 1
close one nostril at a time and give familiar smells
anosmia
loss of sense of smell
How to assess cranial nerve 2
- test visual acuity
- peripheral vision
how to assess cranial nerves 3, 4, 6
- pupil accommodation and reaction to light (direct and consensual)
- extraocular eye movement
how to assess cranial nerve 5
sensory function:
- touch face with cotton ball and repeat with a toothpick
motor function:
- move jaw side to side against resistance then clench or bite down
how to assess cranial nerve 7
sensory function
motor function
- smile, frown, eyebrow movement
how to assess cranial nerve 8
Hearing- whispered voice test
Equilibrium- Romberg test
how to assess cranial nerves 9 and 10
- testing motor function: say ahhhhh
- stimulate gag reflex: needed to prevent choking
- test taste posterior tongue
how to assess cranial nerve 11
motor function of neck and shoulder muscles against resistance
how to assess cranial nerve 12
- protrude tongue and move it side to side, up and down
- pronounce L, D, N, T
stereognosis
recognition of familiar object by touch
graphesthesia
identify number or letter traced in the hand
discriminatory sensations
point localization: ability to sense and locate area being stimulate
0/4 deep tendon reflex
no response detected
1/4 deep tendon reflex
response present but diminished
2/4 deep tendon reflex
response normal
3/4 deep tendon reflex
response somewhat stronger than normal
4/4 deep tendon reflex
response hyperactive with clonus
clonus
the presence of rhythmic involuntary contractions
normal response for bicep deep tendon reflex
- contraction with flexion of forearm
- arm needs to be flaccid
Tricep reflex
abduct pt’s arm and flex it at the elbow. support it with non-dominant hand. strike tendon about 1-2 inches above olecranon process approaching it from directly behind
- make sure arm is limp
brachioradialis reflex
rest pt’s arm on his/her leg and palpate brachioradialis tendon 3-5 cm above wrist. strike with reflex hammer
- arm needs to be limp
tendon reflex
client sits with legs dangling. strike tendon directly below patella
achilles reflex
have client lie supine or sit with one knee flexed. holding the foot slightly dorsiflexed, strike achilles tendon
- should see plantar flexion of foot
superficial reflexes: Babinski
- plantar flexion of toes
- positive = toes fan, not good in adults, normal in children
- negative = no response/ foot withdraw, toes curl, normal for adult
sucking
stimulate lips
rooting
stroke cheek
palmar grasp
place finger in newborn’s hand and they should squeeze
plantar reflex
press thumb on bottom of foot and toes should curl down
moro reflex
startle
tonic neck reflex
turn head side to side in supine position
stepping reflex
marching when being help up
What number indicates severe brain injury on the glascow coma scale?
anything below an 8
cervical lymphnodes
- should be non palpable, if palpable they should be mobile
- need to get it checked if it is large and nonmobile
poterior auricular
behind ear
occipital
near back of head/ occipital lobe
deep cervical
lower neck
superficial cervical
lower ear and parotid
posterior cervical
behind superficial cervical
supraclavicular
above clavicle
preauricular
in front of ear
parotid
below ear
submental
below chin
tonsillar
below temporomandibular joint
submandibular
below mandible
presbyopia
need reading glasses
hyperopia
far sighted
myopia
near sighted
pupil accommodation
eyes cross, pupils constrict
delirium
acute, usually occurs because of a disease and usually goes away after recovery
dementia
onset is usually slow and insidious
depression
describes a negative change in mood that has persisted for at least two weeks
ADLs
bathing, eating, walking, toileting, grooming
IADLs
driving, meal prep, housekeeping, laundry, finances, taking medications
diplopia
double vision
alert
awake and easily aroused
somnolent
abnormally drowsy
lethargic
not fully alert, drifts off to sleep when not stimulated
obtunded
sleeps most of the time, difficult to arouse
stupor
semi coma, unconscious, responds to only persistent and vigorous shaking
coma
unconscious. no response to pain or any external stimuli
