Final Exam Cumulative Flashcards
subjective data + examples; also known as what?
patients’ feelings and statements (“I feel…”) + pain
AKA symptoms
objective data + examples; also known as what?
observable, measurable (VS, labs, assessments)
AKA signs
this type of communication technique can be helpful for changes in patient status, communicating needs, updating providers or other healthcare team members about situation
SBAR
components of SBAR
situation
background
assessment
recommendation
normal adult BP value
systolic <120 / diastolic <80
what is hypertension defined as?
> or = 140/90
normal adult HR
60-100 bpm
normal adult RR
12-20 RR
normal adult temperature
97-99°F
normal adult O2 saturation
> 90%
fever is defined as what value?
> 100.4°F
is rectal temp usually higher or lower than oral?
slightly HIGHER
normal pulse quality value
2+
describe location for apical pulse
5th IC space, midclavicular line
when should you check apical pulse?
irregular HR, cardiac hx, infant + children, BP meds
word to describe absence of breath sounds for 15 seconds
apnea
HYPOtension value
<100/60 or 30 mmHg below patient baseline
name 5 ways to prepare for taking a BP to ensure accurate reading
- no nicotine or caffeine for 30 mins before
- choose correct cuff size
- rest for 5 minutes before taking
- don’t cross legs
- arm supported @ heart level
orthostatic hypotension defined as drop of ___ mmHg in systolic and ___ mmHg drop in diastolic
20 mmHg drop Systolic
10 mmHg drop diastolic
thorough method to assess pain or new condition (reason for seeking care)
OLDCARTS
describe components of OLDCARTS
Onset Location Duration Characteristics Aggravating/Alleviating Related symptoms Treatment Severity
information in a review of systems (ROS) is obtained how?
through PATIENT - subjective !!
the _____ ______ gives us a global impression of the person we’re assessing
general survery
the general survey includes which 4 components?
- physical appearance
- body structure
- mobility
- behavior
“Physical Bodies Move Bashfully”
mood is defined as
a person’s emotional state
affect is defined as
the expression of that emotion
ataxia
defective muscular coordination; walking all over the place; staggering (can resemble ETOH intoxication)
ataxia is cause by dysfunction of what area of the brain?
cerebellum
describe decerebrate posture
-deep tendon reflexes -exaggerated
-pronated palms
-clenched teeth
=MORE SERIOUS
describe decorticate posure
- clenched fists
- legs adducted
- hands come to core
people lose which type of memory last?
remote (months or years ago) - think about how a person with dementia can sometimes still remember stories from their childhood…
paresis
partial or complete paralysis
paresthesia
burning or tingling (r/t nerve injury)
proprioception
being aware of where we are and our body movements
orientation is assesing what?
level of awareness of reality
what questions would you ask for orientation?
- person: who are you? DOB?
- time: what is the day of the week? –> what season is it? (adjust these questions based on their orientation level)
- place: where are you right now?
- situation: what brought you in?
level of consciousness is assessing what?
responsiveness (overlaps with orientation)
re: LOC, fully conscious =
awake/alert
re: LOC, lethargy =
drowsy + sluggish but awakens; needs engagement
re: LOC, obtunded =
fades in and out; confused when awake; needs CONSTANT stimulation to stay awake
re: LOC, stupor =
arouses to vigorous stimulation (usually pain); cannot verbalize or follow commands
re: LOC, coma =
no purposeful response to anything you do to them
re: reflex responses, what is a normal/average score?
2+
re: reflex responses, what is the score for hyperactive w/clonus and ABNORMAL
4+
re: Morse Fall Scale, what is a low risk score?
moderate risk score?
high risk score?
0-24
25-45/50?
> 45-50
re: Morse Fall scale, what is a low risk score?
0-24
re: Morse Fall Scale, what is a high risk score?
> 45/50
describe Romberg Test and what a positive result would be?
patient stands with feet together, eyes closed + arms at side
provider gently pushes patient
positive result: patient sways, widens stance or loses balance
term for recognizing an object by touching it with eyes closed
stereognosis
term for the ability to recognize numbers or letters written on palm with eyes closed
graphesthesia
the glascow coma scale assesses which 3 things?
- eye opening
- verbal response
- motor response
= can you open your eyes? can you talk? can you move?
re: Glasgow Coma Scale, which score usually indicates coma?
less than 8
the higher the number the better - 15 is highest
Purpose of functional assessment
function r/t ADLs - what can you do and how well?
ROM assessment should show what?
smooth, painless, movement through motion
describe passive ROM (PROM)
nurse anchors joint with one hand and uses other to move body part
two of the most important things to remember with ROM
- keep eyes on patient to indicate pain (nonverbals)
- STOP if resistance or pain is felt!
joint exam findings - snap, crackle, pop =
crepitation
ankylosis =
stiffness or fixation of joint
subluxation =
partial dislocation of joint
atonic =
no tone or movement
spasticity =
sudden muscle contractions
flaccidity =
weakness
atrophy =
wasting
hypertrophy =
increased muscle mass
contracture =
shortened muscle
fasciculation =
muscle twitch
re: muscle testing, what score would you give for someone who can move joint with passive ROM
2
re: muscle testing, what score would you give for someone who can move against gravity
3
re: muscle testing, what score would you give for someone who can move against some resistance
4
re: muscle testing, what score would you give for someone who can move against FULL resistance
5
difficulty breathing while lying down
orthopnea
what valves are closing during S1 (“lub”)?
mitral and tricuspid
what valves are closing during S2 (“dub”)?
aortic and pulmonic
where can we hear S1 the best?
apex
where can we hear S2 the best?
base of heart (up top)
what mneumonic can you use for landmarks of the heart?
2245 APT M
2nd IC space R of sternum (aortic)
2nd IC space L of sternum (pulmonic)
4th IC space L of sternum (tricuspid)
5th IC space L of sternum (mitral = apex)
what are the AV valves?
mitral + tricuspid
what are the semilunar valves?
aortic + pulmonic
where can the PMI be felt?
5th IC space midclavicular line = apex
where can you find Erb’s Point? why is it a helpful landmark?
3rd IC space L sternal border = can hear everything about the same!
term for a high-pitched scratchy/grated sound + what causes it?
friction rub r/t pericardial inflammation
describe differences between MI in male + female
men = chest pressure women = more likely to report N/V, sweating, pain in neck, jaw, abdomen, back; unusual fatigue; sleep disturbance; SOB; impending doom :(
blowing or swishing sound (using bell)
bruit
what is a normal capillary refill?
< 2-3 ish seconds
pitting edema
leaves indention
1+ pitting edema =
depresses 2mm (x2) disappears rapidly
2+ pitting edema =
depresses 4mm (x2)
3+ pitting edema =
depresses 6mm (x2) lasts a minute or so
edema becoming visibly obvious at this stage
4+ pitting edema =
depresses 8mm (x2) lasts 2 mins or more
S+S of DVT
UNILATERAL edema
erythema
warmth
pain, ache, cramps
DON’T MOVE
which peripheral disorder is worse with activity?
arterial disorder (blood not getting where it needs to go)
which peripheral disorder improves with activity?
venous disorder (blood can move from pool and get back to heart)
what peripheral disorder is characterized by intermittent claudication?
arterial (pain after exercise)
re: arterial disorder, what movement with feet will reduce pain?
lowering feet
re: venous disorder, what movement with feet will reduce pain?
elevating feet (sends blood back to heart)
what will the skin look like with arterial disorder?
cool, cold, shiny, hairless, pallor (w/elevation), NO edema
what will the skin look like with venous disorder?
mottled, warm, edematous
pulses present in arterial or venous disorder?
venous
S+S of acute arterial disorder
6 P’s
- pain
- poikilothermic
- pallor
- paresthesia
- paralysis
- pulselessness
pallor
pale/greyness
cyanosis
blue-ish purple-ish
can be pale in people with more melanin
what could pallor indicate?
anemia; reduced blood flow
where is a good location to assess for pallor (regardless of melanin levels in skin)
conjunctival sacs
what can cyanosis indicate?
hypoxia
acrocyanosis is found where?
extremities
circumoral cyanosis is found where?
around the mouth
where does jaundice initially occur before it spreads?
mouth + palates + mucous membranes
hypopigmentaton is also called what?
VITILIGO
macule
flat, small
papule
solid, small, elevated
pustule
raised, pus-filled
vesicle
elevated, small, serous filled
loss of outer layers from itching/rubbing
excoriation
cleft into the skin, often from drying
fissure
large, dark, palpable scar w/increased collagen
keloid
confluent skin issues
run together - think confluence of a river
arciform skin lesions
with arcs, rings; circle within a circle
ex: annular lesion
re: skin lesions what is diffuse distribution
widespread, generalized, over entire body
re: skin lesions, what is localized
limited + discrete
re: skin lesions, what is one lesion in each area called? (separated from each other)
discrete
cherry red proliferation of blood vessels
hemangioma
petechiae
tiny, pinpoint hemorrhages
purpura
flat hemorrhage, larger area
hematoma
elevated bruise; can be palpated
ecchymosis
capillary bleeding into tissue; not palpated; will see color progression
what method do we use for assessing moles/skin lesions? (skin cx)
ABCDE asymmetry border color diameter elevation/enlargement
hirsutism
excessive hair growth in unusual places
paronychia
inflammation/ infection of nail bed
clubbing can indicate what?
chronic hypoxia
define approximated
pulled together, matched up, closed wound
stage 1 pressure injury
non-blanchable redness
stage 2 pressure injury
epidermis removed; partial thickness
stage 3 pressure injury
full thickness; into subcutaneous tissue; may see eschar + slough; could see undermining + tunneling
stage 4 pressure injury
full thickness; into the bone, tendon, muscle
unstageable pressure injury
cannot visualize bottom of wound bed - don’t know what’s under there
6 components of Braden Scale (to predict pressure injury risk)
- sensory perception
- moisture
- mobility
- friction/shear
- activity
- nutrition
how is Right lung different from left lung?
right has 3 lobes (middle lobe), left has 2
when auscultating posterior lung fields, which landmark do you start at?
C7 - work in ladder-like fashion down
what signs might you see with dyspnea?
- nasal flaring
- retraction
- pursed lips
- labored breathing
re: thoracic assessment, describe pectus excavatum
caved in
re: thoracic assessment, describe pectus carinatum
bird beak
CARINatum = CANARY bird
re: thoracic assessment, describe barrel chest
bulging and rounded; AP diameter is equal
hyperventilation is what RR?
> 24
hypoventilation is what RR?
<10
which type of breathing pattern is this: rate + depth are variable w/periods of apnea; aka “end of life breathing” or “death rattles”
cheyne-stokes
which type of breathing pattern is this: increased depth + rate with abrupt pauses; associated with head trauma
Biot’s
which type of breathing pattern is this: abnormally deep w/increased rate; associated with DKA
kussmaul
what could cause increased tactile fremitus?
pneumonia, phlegm, tumor (sound + vibration travels much quicker / easier through liquid)
what could decrease tactile fremitus?
COPD, emphysema, pleural effusion, pneumothorax
what sounds do you hear over lung fields; the majority of the sounds heard?
vesicular
what sounds do you hear over the trachea?
bronchial
what sounds do you hear near sternum?
broncho-vesicular
define this abnormal breath sound:
crackles or popping
crackles
can crackles be cleared by coughing?
no (fluid is too deep)
define this abnormal breath sound:
moaning, snoring, gurgles
rhonchi
can rhonchi be cleared by coughing?
yes
define this abnormal breath sound:
whistling, musical sound
wheezes
define this abnormal breath sound:
squeaking or grating sound
pleural friction rub
define this abnormal breath sound:
crowing (can usually hear w/o a stethoscope)
stridor
MEDICAL EMERGENCY!
constipation is defined as what?
BM < 3 x / week
what is the unique order of assessment with the GI system?
auscultate before palpation or percussion
re: abdomen, describe a scaphoid shape
concave
re: abdomen, describe a protuberant shape
PROTRUDING out
obesity, pregnancy, ascites
what should you do if you find a bulging mass on the abdomen during your GI assessment?
DON’T PALPATE + GET HELP!
for a GI assessment, which quadrant should you start at? and how should you move?
RLQ (ileocecal valve)
clockwise direction
what conditions could cause hyperactive bowel sounds?
diarrhea, just ate (increased peristalsis)
what conditions could cause hypoactive bowel sounds?
post-op, constipation, decreased peristalsis
definition of ABSENT bowel sounds
no sounds for 5 minutes TOTAL
re: stool assessment, frank red color could indicate what?
bleeding close to source (hemorrhoids)
re: stool assessment, maroon/dark red color could indicate what?
bleeding in upper GI tract (time to hemolyze) - small intestine is possibility?
frank red would be lower GI bleeding
re: stool assessment, black/not sticky stool could indicate what?
- iron supps
- Pepto Bismol (bismuth) use
re: stool assessment, brown, clay-colored could indicate what?
little to no bile
re: stool assessment, yellow/greasy could indicate what?
increased fat content in diet
re: emesis, frank blood could indicate what?
esophageal bleeding or bleeding close to source
re: emesis, “coffee grounds” could indicate what?
GI bleed (blood clots in emesis)
describe expected stool consistency from a COLOSTOMY
resembling expected/usual stool - more formed since ostomy is lower down in GI tract
describe expected stool consistency from an ILEOSTOMY
loose stool (ostomy is in small intestine so not as much H2O absorption)
what are the assessment findings of a healthy stoma
beefy red, healthy periostomal area
NOT retracted, NO edema, NO bleeding
at what level of fullness should you empty an ostomy bag?
1/3; NO MORE than 1/2!
describe the “Fluid Wave” assessment for ascites
- Place ulnar surface of hand firmly on midline of abdomen
- Strike one side of abdomen with fingers and feel impulse of fluid with other hand
describe “Shifting Dullness” assessment for ascites
- 1st Patient lying supine
- find tympany in center of abdomen
- percuss outward in several directions to denote dullness
- ask patient to turn to one side then percuss for tympany to dullness (fluid sinks to lowest point)
describe rebound tenderness assessment for peritoneal irritation (possible ruptured appendix)
- applies pressure to an area of abdomen
- More painful when pressure is released
describe kidney tenderness assessment
o Find costovertebral angle
o Place left hand flat in this area on one side; hit hand sharply with fist of other
o If tenderness present, patient will indicate!!!
what is minimum volume for voiding per hour?
30mL/hr
oliguria is defined as what?
<20mL/hr or <400mL/day
what is anuria?
NO URINE
polyuria is defined as what? and what condition might we see this in?
increased volume; DM
what is a bladder scanner assessing for?
urinary retention
post void residual
at what age do mammograms usually begin?
40 yrs old; earlier with risk factors
re: breast exam, describe describe Peau D’Orange
dimpling, puckering r/t breast cx; resembles skin of an orange
describe some abnormal findings in a breast and lymph node exam?
hard, non-mobile, cannot feel edges, asymmetrical, not cyclic, located in tal of spence
(expected findings are opposite of this)
epistaxis =
nose bleeds
edentulous =
without teeth
leukoplakia
thick white patches that cannot be scraped off
describe the different grades of enlarged tonsils
- 1+ less than 25% (visible tonsils)
- 2+ less than 50% (enlarged halfway)
- 3+ less than 75% (tonsils almost touching uvula)
- 4+ kissing tonsils (tonsils almost touching each other)
what is PERRLA assessing?
2 things to look for
Pupils Equal Round and Reactive to Light + Accommodation
- direct pupil rxn
- consensual pupil rxn
what is the expected finding for accomodation w/PERRLA?
bilateral pupil contraction as you near nose
anisocoria
uneven eyes/different size pupils
miosis
small, tiny, constricted pupils
myadrasis
dilated, fixed pupils
visual acuity is tested with what?
Snellen chart (20/20) - describe this
amblyopia
“lazy eye”
ptosis
droopy eyelid
lacking symmetry
where do you place tuning fork with Weber test?
on top of head
can they hear equally with both ears?
where do you place tuning fork with Rinne test?
on mastoid bone
is AC>BC?
what tests would we use for depression screening?
Patient Health Questionnaire (PHQ) 2 –> PHQ 9 if they are positive for the other 2 questions
S+S of agitation
- repetitive motor activity
- foot tapping
- hair pulling
- fiddling
- repetitive vocalizations
- irritability
- heightened response to stimuli
- aggression
