Final Review Flashcards
what technique to elicit crepitus on chest injury?
palpation
what technique for diaphragmatic excursion?
percussion
what technique for full/distended bladder?
indirect percussion
what technique for the sinuses?
direct percussion
what technique for the lungs?
indirect percussion
transilluminator
detect blood, fluid, or masses in body cavity
wheal
reddend, irreg border
- ie/ insect bite, hives
lichenification
rough, thick, hardened epidermis due to constant scratching/rubbing
venous lake
vascular lesion
elevated, dark blue, compressible soft lesion on the lip or neck
- common in elderly
port wine stain
vascular lesion
falt, irreg, pale-deep purple red;
color deepens in response to emotion or high temp
hemengioma
vascular lesion
bright red, raised, nonblanch
- present @ birth - few months after
- disappears at age 10
spider angioma
vascular lesion
flat red dot w/ tiny radiating vessels; pinpoint - 2 cm; blanchable
light palpation
fingerpads of 1 hand
- 0.5-1 cm
moderate palpation
fingerpads
- 2-3 cm
deep palpation
palmar surface; bimanual
- 4-5 cm
- liver, spleen, kidneys
indication:
open sore on hand; not healed for several months
malignancy/skin cancer
nystagmus
jerky eye movement during 6 cardinal field of gaze
weber test
normal: equal lateralization to right and left ears
- abnormal: impacted cerumen; lateralization towards the ear w/ cerumen
rhine test
normal: air conduction 2x greater than bone conduction
craniosynostosis
infant w/ elongated head; altered face and orbit of eyes
presbyopia
difficulty with near vision
- common in ages 45+
hyperopia
difficulty w/ near vision
myopia
difficulty w/ far vision
acute glaucoma
increase pressure in the eyes
- S/Sx: sudden pain; ↓ vision; halos around light; dilated, oval pupil; cloudy cornea w/ curcumcorneal redness
- Outcome: may lose vision in 1-2 hours
- Tx: surgery
- EMERGENCY; IMMEDIATE ATTENTION
otitis externa
infection of outer ear; tympanic normal, pearly grey
otitis media
infection external & ossicles
otitis interna
(labyrinthitis)
infection in the semicircular canal, cochlea, & vestibule
- S/Sx: severe vertigo, dizziness
otoscope
funnels light into ear canal
retinal detachment
- S/Sx: diminished vision; floaters; sudden flash; shadow in vision
- Outcome: lose vision withing days of diagnosis
- Tx: laser surgery (photocoagulation); freezing (cryopexy)
how to assess EOM
6 cardinal fields of gaze
- H or wheel wagon method
leading cause of blindness in US?
diabetic retinopathy
how to test integrity of cranial nerve III?
look up and down without moving head
indication:
white patches of tympanic membrane
scarring from previous infection
nursing care:
positive rombergs test
provide bedside comode
sinus headache
from sinus infection
classic migraine
preceded by aura; spots and flashes; numbness/tingling of face and extremities
cluster headache
numerous headaches over days-months; no aura; sudden onset
- associated w/ alcohol, stress, or emotional distress
- may last for a few minutes-hours
tension headache
(muscle contraction headache)
gradual onset; steady pain; starts from cervical to top of head; unilateral or bilateral
- associated with stress, overwork, dental problem
intropion
inverted upper lid
- irritation of eyes
ectropian
lower lid everted
- exposes conjunctiva
most common hyperthyroidism
graves’ disease
gingivitis
- S/Sx: red, bleeding, receeding gums
expected finding:
bell’s palsy
- muscle distortion
- pain behind ears
- impaired taste
expected finding:
1) no fluid in sinus
2) fluid in sinus
1) red glow
2) no red glow
SBE for elderly client
the same day every month
SBE for mensturating client
3-5 days after cycle
- hormones are more stable
common cause of benign nipple discharge
intraductal papilloma
- postmenopausal client
- serous/bloody discharge
benign breast
(fibrocystic disease)
- S/Sx: lumps, pain/tenderness, and nipple discharge due to thickening of breast tissure
- common in womens 20’s
fibroadenoma
defined breast tumor w/ NO tenderness/discharge
- common in ages 15-35
Peau D’ Orange
orange peel appearance
- indicates malignancy
most reliable indicator of central cyanosis in asthma client
oral mucosa
early signs of hypoxia
- altered LOC
abnormal findings:
whispered pectriloguy w/ bilateral PNA
(both lungs filled w/ fluid)
loud, clear bilaterally
expected findings:
whispered pectriloguy
auscultate technique
soft, indistinguishable
technique to assess respiratory system
assessing from side to side
tracheal
normal lung sounds
harsh, high-pitch
- I < E
- over trachea
bronchial
normal lung sounds
loud, high-pitch
- E > I
- next to trachea, above each clavical, 1st ICS
broncho-vesicular
normal lung sounds
medium, medium-pitch
- I = E
- over major bronchi in 2nd & 3rd ICS; between scapulae
vesicular
normal lung sounds
soft, low-pitch
- I > E
- remainder of the lungs
bradypnea vs hypoventilation
abnormal breathing patterns
< 10 breaths/min; slow
- bradypnea: regular
- hypoventilation: irregular
tachypnea vs hyperventilation
abnormal breathing patterns
> 20 breaths/min; rapid
- tachypnea: shallow
- hyperventilation: deep
cheyne-stokes vs biot’s (ataxic)
abnormal breathing patterns
periods of apnea
- cheyne-stokes: regular; in dying patients
- biot’s (ataxic): irregular; brain damage
crackles
adventitious sounds
low-pitched, bubbling, loud
- due to collapsed, fluid filled lungs
- *ie/ lobar pnuemonia
rhonchi
(sibilant)
adventitious sounds
high-pitched, continuous
- due to blocked airflow
- ie/ asthma
rhonchi
(sonorous)
adventitious sounds
low-pitched, continuous, snoring, rattling
- ie/ COPD
stridor
adventitious sounds
loud, high-pitched, crowing heard W/O stethoscope
- common in obstructive upper airway
friction rub
adventitious sounds
low-pitched, grating, rubbing
- *ie/ pleural inflammation
expected findings:
normal chest
chest configuration
elliptical with lateral diameter 2:1 with anteroposterior diameter
- usually by age 6
expected findings:
infant chest
chest configuration
rounded; equilateral in anteroposterior diameter; barrel chest
- COPD = barrel chest
abnormal findings:
pectus carinatum
(pigeon chest)
congenital chest deformities
forward displacement of sternum w/ depression of adjacent cartilage
- no tx required
abnormal findings:
pectus excavatum
(funnel chest)
congenital chest deformities
depression of sternum & adjacent cartilage
- cradiac murmur
- surgery required in severe cases
abnormal findings:
scoliosis
chest configurations
lateral curve of spinal process
- common in female
abnormal findings:
kyphosis
chest configurations
exaggerated posterior curve of thoracic spine
- associated w/ aging
abnormal findings:
lordosis
chest configurations
exaggerated curve of lumbar spine
- during last term of pregnancy
indication:
hyperesonant sound on percussion of lungs
breath sounds
air trapped in lungs
abnormal findings:
pleural effusion
auscultation of breath sounds
absent breath sounds of affected lung
indication:
low-pitched, loud, moist, bubbling on auscultation
adventitious lung sounds
fluid filled alveoli
what part of the chest do you perform cardiac assessment?
precordium
location of PMI
(point of maximal impact)
left midclavicular line; 5th ICS
erb’s point
cardiac landmark
3rd ICS; LSB
angle of louis
cardiac landmark
articulation of manubrium & body of sternum in line w/ 2nd rib
abnormal findings:
arterial insufficiency
peripheral vascular
- cold, no hair
- deep muscle pain from activity/elevation of limb
abnormal finding:
venous insufficiency
peripheral vascular
- temp is normal, edema
- pain from prolonged standing/sitting
ECG
(electrocardiogram)
electrical representation of cardiac cycles, documented by a deflection on a recording paper
depolarization
(contraction)
ECG
after stimulation by electrical current
- inside cardiac cells: + charge
repolarization
(relaxation)
ECG
after contraction
- inside cardiac cells: - charge
P wave
ECG
atrial depolarization
- ~ 0.08 secs
PR interval
ECG
time needed for electrical current to travel across both atrium & arrive at AV node
- 0.12 - 0.20 secs
where is atrial polarization hidden in?
ECG
QRS interval
QRS interval
ECG
ventricular depolarization
- .08 - 0.11 secs
T wave
ECG
ventricular repolarization
QT interval
ECG
beginning of ventricular depolarization to moment of repolarization
(ventricular contraction)
allen’s test
determines the patency of radial and ulnar ateries
abnormal findings:
raynaud’s disease
peripheral vascular
spasm/tingling of hands & fingertips turn whitish → cyanotic → reddish
- common in young, healthy females 2/2 connective tissue disease, drug intoxication, pulmonary HTN, or trauma
deep vein thrombosis
(DVT)
peripheral vascular
occulsions of deep veins by blood clot
- sudden swelling on one leg
- dependent edema
- IMMEDIATE REFERRAL; can become VTE → lung = PE
subjective findings:
DVT
peripheral vascular
- intense, sharp pain along the iliac, popliteal, or calf muscle
- intense pain w/ dorsiflexion of foot
objective findings:
DVT
peripheral vascular
- unilateral edema
- low grade fever
- tachycardia
abnormal findings:
infective endocarditis
thin red lines or splinter hemorrhages on nail beds
pathological cardiac murmurs
structural abnormalities of the heart
- mitral regurgitation
- tricuspid stenosis
- aortic regurgitation
aortic area
cardiac landmark
2nd ICS, RSB
S2
(dub)
heart sounds
closure of the semilunar valves
- loudest at the base of the heart
S1
(lub)
heart sounds
closure of the tricuspid and mitral valves
- loudest at the apex of the heart
SA node
pacemaker of the heart; where the initial electrical impulse occurs
- 60 - 100 joules/min
AV node
60 joules/min
bundle branches
40 - 60 joules/min
S4
(atrial gallop)
heart sounds
before S1
S3
(ventricular gallop)
heart sounds
after S2
what are the major risk factor for diseases?
smoking, HTN, DM, obesity, & high cholesterol
foramen ovlale
congenital heart diseases
passage way for blood between the atriums
- should close shortly after birth
ductus arteriosus
congenital heart diseases
opening between the pulmonary artery and the descending aorta
- should close 24 - 48 hours after birth
tetralogy of fallot
congenital heart diseases
- 4 cardiac defects
- life threatening; sx right away
sympathetic
cardiac nerves
stimulates the heart
- ↑HR, ↑ dilation of coronary arteries
parasympathetic
cardiac nerves
↓ stimulation of the heart
- ↓HR, ↓ contraction of heart, and ↓ dilation of coronary the coronary arteries
manifestations:
heart failure
cardiac diseases
- fatigue
- tachycardia
- SOB/dyspnea
- weak paripheral pulses
- S3
- ankle edema
what technique to assess patency of arterious venous graft?
(AV graft)
palpate the side for thrill
2 types of abdominal mapping
- 4 quadrants
- 9 regions
costovertebral angle tenderness
(CVAT)
abdominal landmark
costovertebral angle using blunt percussion
indication:
input > output
retaining fluid
- CHF
indication:
output > input
secreting more fluid that intaking
- DM, kidney failure, excess intake of fluids
positive blumberg sign
abdominal abnormal findings
sharp, stabbing rebound pain
- positive peritonitis/peritoneal irritation
- EMERGENCY
positive rovsing sign
abdominal abnormal findings
sharp pain in RLQ when palpating LLQ
- acute appendicitis/peritoneal irritation
positive psoas sign
abdominal abnormal findings
RLQ pain when R leg is raised up w/ resistance
- appendicitis
positive murphy’s sign
abdominal abnormal findings
RUQ pain when deep breathing while palpation of lower border of liver
- cholecystitis
positive cullen’s sign
abdominal abnormal findings
ecchymosis/blueish discoloration of abdomen
- ruptured ectopic pregnancy
- internal bleeding in abd
location of mcburney’s point
middle 1/3 of the imaginary line from the umbillicus to the right inguinal area
normal findings
thin person
abdominal contours
flat
normal findings:
very thin person
abdominal contours
scaphoid
normal findings:
obese; toddler; early pregnancy
abdominal contours
rounded
normal findings:
some toddlers; late stage pregnancy; ascites
abdominal contours
protuberant
abdominal aortic aneurysm
(AAA)
strong abdominal pulsation
- EMERGENCY
LUQ organs
stomach; spleen
RUQ organs
liver; gallbladder
what quardant to assess for diverticulitis
LLQ
sequence of assessing the abdomen
1) inspect
2) auscultate
3) percuss
4) palpate
hepatitis
inflam. of liver caused by:
- virus, bacteria, chemicals, drugs, parasite
hepatitis B & D
transmitted by:
- blood
- sexually
- perinatally
- parenterally
hepatitis C
transmitted by:
- blood
- parenterally
hepatitis A
transmitted by:
- fecal/oral
- common in children
hepatitis E
transmitted by:
- drinking dirty water
- common in travelers
anuria
urinary conditions
< 100cc in 24 hrs
oliguria
urinary conditions
100 - 400cc in 24 hrs
enuresis
urinary conditions
involuntary urination at night
- common in ages 5 and younger
- familial tendency
normal bowel sounds in each quadrant
irregular, high-pitched, gurgling
- 5 - 30/min
borborygmi
- normal: frequent, loud bowel sounds when a person has not eaten in 5-7 hours
- abnormal: when accompanied by other GI symptoms (bleeding, IBD)
indication:
hyperactive
bowel sounds
diarrhea; gastritis
indication:
hypoactive
bowel sounds
post-op; bowel obstruction; constipation
indication:
absent
bowel sounds
paralytic ileus; complete bowel obstruction
collitis
abdominal disorder
inflam. of colon
- S/S: abd pain, diarrhea, bloody stool
- may require medical intervs.
crohn’s
abdominal disorder
chronic inflam. of the GI; any part of lower intestines
- S/S: abd pain, diarrhea, weight loss
- no medical interv
glomeruli
clusters of capillaries in kidneys
- filter 1L/min
manifestations:
chronic renal failure
- UREMIA
- S/S: N/V, anorexia, altered mentation, uremic frost on skin, edema, fatigue, weight loss
cause & manifestations:
HYPERnatremia
- Cause: exposure to extreme environmental temp
- S/S: hypotension, weakness, tachycardia, dry mucosa, oliguria
diencephalon
thalamus, hypothalamus, epithalamus
tremors of parkinson’s
rhymic shaking
why do you get shorter when you age?
shortening of vertebral column
osteoarthritis
pain aggravated by activities
rheumatoid arthritis
pain improve with activites
risk of osteomyelitis for open metacarpal fracture
fever
ABduction
move outward/away from center of body
ADduction
move inward/toward center of body
risk factors for osteoporosis
sedentary lifestyle; no exercise
abnormal findings:
positive carpal tunnel syndrome
(phalen’s test)
tingling/numbness over media nerve, palmar of thumb, index, middle, ring; pain of upper arm, shoulders, neck, chest
(hold wrist @ 90° flexion for 60 secs)
tinel’s sign
direct percussion on median nerve
- normal: no pain/tingling on arm along median nerve
indication:
rotator cuff injury
inability to ABduct arm at shoulder
brachioradialis
tap flat of DTR hammer 2-3in above wrist when palm in semi-prone w/ elbows aligned w/ waist
bicep reflex
tap indirectly point of DTR hammer @ antecubital of arm when palm in semi-prone w/ elbows aligned w/ waist
ataxia
diff. w/ ambu D/T unsteady gait; wide base; swaying
- common in multiple sclerosis, drug/alcohol intox
graphesthesia
(two point discrimination)
draw letter on clients hand w/ eyes closed
- inability may indicate cortical diseases
stereognosis
identify familiar object place on hand w/ eyes closed
- inability may indicate cortical diseases
how to assess for sensory function
sharp or dull touch w/ eyes closed
normal achilles tendon reflex
plantar flexion of foot and heel jump
risk for autonomic dysreflexia in T4 spinal injury patient
clients bladder becomes distended
bell’s palsy
one-sided inflam. of CN VII
- S/S: pain behind ears w/ tinnitus; no headache; impaired taste; diff w/ speech & eating; muscle distortion
babinski reflex
extend and fan toes & flex foot
- normal up to 24 months
- in >24 months indicates: CNS pathology; upper neuron disease
plantar reflex
stim sole of foot, from heel across ball of foot to big toe in an inverted ‘J’
- normal adults: plantar felxion, toes curl towards sole of foot
expected and unexpected findings:
when assessing CN 12
- Expected: ease and eqaulity of movement
- Unexpected: tremor, paralysis, diff. w/ speech or swallowing
objective findings:
meningitis
- fever, irritability, vomit, seizure, coma
