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Health Assessment Test 2 Flashcards

1
Q

vascular system

A
  • job is to circulare blood and lymph with arteries, veins, and lymphatics
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2
Q

arteries

A
  • deliver freshly oxygenated blood to body, strong, tough vessels that must withstand high pressure demands, expands and recoil with heartbeat/pulse
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3
Q

veins

A
  • bring blood back to the heart to go through lungs to be oxygenated, lie closer to the skin surface than arteries, are more elastic/distensible, contain valves so blood cannot flow backwards
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4
Q

lymphatics

A
  • made up of vessels, nodes, ducts, some organs
  • brings excess fluid and plasma proteins back to the bloodstream from the interstitial space
  • major part of the immune system
  • absorb lipids from the small instestine
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5
Q

superficial veins in the legs

A
  • great and small saphenous
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6
Q

cervical nodes

A
  • drain the head and neck
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7
Q

axillary nodes

A
  • drain the breast and upper arm
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8
Q

epitrochlear node

A
  • drain the hand and lower arm
  • located in the antecubital fossa
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9
Q

inguinal nodes

A
  • drain the lower extremities, the external genitalia, and the anterior abdominal wall
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10
Q

pregnant female developmental considerations

A
  • increased estrogen levels leads to vasodilation and drop in BP
  • uterus exerts pressure on iliac veins and inferior vena cava which results in edems and varicose veins
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11
Q

aging adults developmental consideration

A
  • arteriosclerosis from increased rigidity of the peripheral blood veels
  • increased risk for deep vein thrombosis
  • decreased lymphatic tissue
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12
Q

leg pain/cramp assessment subjective data

A
  • note location, type, precipitating factors, caludication distance, relived by rest walking, rubbing, night pain, recent change in exercise, past history of vascular problems
  • note sudden worsening of claudication and pain suddenly relieved with rest
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13
Q

skin changes assessment subjective data

A
  • discolorations (redness, pallor, blueness, brownish), varicose veins, coolness, sores, or ulcers
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14
Q

arm/leg swelling subjective data

A
  • in one side or both, worse in the morning or evening, constant or intermittent, what makes it better, what makes it worse, associating factors (pain, heat, redness, ulcers, hardened skin)
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15
Q

lymph node enlargement subjective data

A
  • location, duration, any recent changes, presence of pain or infection
  • if enlarged, it indicates infection, immunologic disease, or malignant disease
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16
Q

medications subjective data

A
  • oral contraceptives or hormonal replacement (increased risk for thrombosis)
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17
Q

full bounding pulse

A
  • 3+
  • indicates hyperkinetic states (exercise, anxiety, fever, and hyperthyroidism)
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18
Q

weak pulse

A
  • 1+
  • indicates shock and peripheral arterial disease
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19
Q

signs of malnutrition

A
  • thiny, shiny, atrophic skin, thick-ridged nails, hair loss, ulcers, gangrene
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20
Q

brownish discoloration

A
  • indicated chronic venous stasis
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21
Q

venous ulcers

A
  • located on the medial malleolus
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22
Q

arterial ulcers

A
  • located on the tips of toes, metatarsal heads, or lateral malleoli
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23
Q

bruit

A
  • indicates turbulent blood flow from partial occlusion
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24
Q

modified allen test

A
  • evaluates the adequacy of collateral circulation prior to cannulating the radial artery
  • watch for persistant pallor or sluggish return of color
  • indicates occlusion of collateral circulation
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25
doppler ultrasound stethoscope
- used to detect a weak peripheral pulse - watch for presence of a swishing, whooshing sound which - indicates a pulse
26
chronic arterial insufficiency
- deep muscle pain - pain with walking claudication - coolness, pallor - dimished pulse - thin, shiny skin - absence of hair - necrotic ulcers on toes, heels, laterla malleolus
27
chronic venous insufficiency
- dull ache, heaviness in lower leg pain - pulses present - thick brawney, edematous skin - brown pigmintation - weeping ulcers on medial malleolus
28
chronic venous stasis
- aching, heaviness, night leg or foot cramps - dilated, tortuous veins
29
acutre venous thrombosis
- sudden onset pain - increased warmth, swelling, redness - watch for homan's sign (not diagnostic)
30
homan sign
- calf pain at dorsiflexion of the foot
31
pitting edema grading
- 1+ mild - 2+ moderate - 3+ deep pitting - 4+ very deep pitting
32
lyphedema
- nonpitting edema, unilateral, overlying skin is indurated and brawy
33
Raynaud's syndrome
- cause areas of the body like fingers and toes to feel numb and cold in response to cold temperatures
34
derived weight measures include
- body weight as percent of ideal body weight - percent of usual body weight - recent weight change
35
body mass index
- marker of optimal weight for height and indicator for obesity and protein-calorie malnutrition - weight/height(2) * 703
36
hemoglobin and hematocrit
- indicators of iron status
37
cholesterol with triglycerides, LDL, and HDL levels
- indicators of cardiovascular risks
38
marasmus
- protein-calorie malnutrition
39
kwashiorkor
- protein malnutrition
40
epidermis
- replaced every 4 weeks - outermost layer - think but tough - houses keratin
41
dermis
- inner supportive layer - consists of connective tissue - contains elastic tissue - nerves, sensory receptors, blood vessels, and lymphatics housed here
42
subcutaneous
- adipose tissue - stores fat for energy - provides insulation for temperature control - cushions and protects
43
functions of the skin
- protects (thermal, physical, chemical, UV, microorganisms) - perception (houses sensory end organs for touch, pain, and pressure) - temperature regulation (heat dissipation through sweat glands and heat storage through subcutaneous tissue) - identification (finger print, hair, skin color) communications (blushing, blanching, expressions) - wound repair - absorption/excretion - vitamin D production
44
infants developmental care
- languo (fine hair) - vernix caseosa (white, cheesy substance) - high risk for fluid loss - poor thermal regulation
45
pregnancy developmental care
- increased sweat and sebaceous gland - increased fat deposits primarily in butt and hips - linea nigra - mid-abdominal dark line - melasma- increased pigment in the face - striae gravidarum - stretch marks
46
older adults developmental care
- thin epidermis (low elasticity, high dryness) - less protective mechanisms (functioning decreases)
47
skin conditions more prominent in African Americans
- keloids, pigmentary disorders, pseudofolliculitis, melasma
48
keloid
- scars with increased height and weight
49
pigmentary disorders
- increased incidence of pigment problems
50
pseudofolliculitis
- razor bumps, razor burn, ingrown hairs
51
melasma
- patchy tan to dark brown discoloration of the face
52
xerosis
- excessive dryness
53
seborrhea
- excessive skin moisture
54
nevus
- mole - ABCDE
55
pallor
- white - anemia, shock, arterial insufficiency, anxiety, fear, exposure to cold, cigarette smoke
56
erythema
- redness - fever, local inflammation, blushing
57
cyanosis
- blue - lower perfusion, unoxygenated hgb
58
jaundice
- yellow - excessive billirubin, sclera, and hard and soft palate of mouth
59
fear/anger
- peripheral vasoconstriction - pallor
60
embarrassment
- facial/neck/flushing - erythema
61
edema
- accumulation of fluid in intercellular space
62
cardiovascular system
- contains the heart and blood vessels
63
precordium
- region on the anterior chest, over the heart and great vessels
64
medaistinum
- the middle third of the thoracic cavity between the lungs - contains the heart and great vessels
65
base
- top of the heart
66
apex
- bottom of the heart
67
great vessels
- superior and inferior vena cava - aorta - pulmonary veins
68
atrioventricular valves
- tricuspid and bicuspid (mitral)
69
semilunar valves
- pulmonic and aortic
70
P wave
- depolarization of the atria
71
PR interval
- from the start of the P wave to beginning of QRS
72
QRS
- depolarization of ventricles
73
T wave
- repolarization of ventricles
74
QT interval
- electrical systole of the ventricles
75
s1
- closure of the mitral and tricuspid valces - indicated beginning of systole
76
s2
- closure of the aortic and pulmonic valves - indicated beginning of diastole
77
effect of respiration
- inspriation-> decreased intrathoracic pressure -> increased venous return to the right side of heart -> increased right ventricular stroke volume -> aortic valve closes earlier -> normal split s2
78
s3
- ventricular gallup - caused by ventricles being resistant to filling during the rapid filling phase (systolic heart failure) - heard right after s2
79
s4
- atrial gallup - present at the end of the diastole with resistance of the ventricles to fillling (diastolic heart failure)
80
murmurs
- results from turbulent blood flow caused by increased velocity, decreased viscocity, structural defects
81
heart sounds described by
- frequency or pitch - intensity or loudness - duration, late - timing
82
preload
- venous return - the volume of blood in the ventricle at the end of diastole
83
frank-starling law
- the greater the stretch, the stronger the cardiac contraction
84
afterload
- the resistance the heart has to pump against
85
carotid arteries
- lies between the trachea and the sternomastoid muscle
86
jugular venous pulse and pressure
- reflect the filling pressure and volume in the right side of the heart
87
internal jugular
- larger, located deep and medial to the sternomastoid - generally not visible - diffuse pulsation may be visible in the sternal notch muscle in supine position
88
external jugular
- more superficial - located lateral to the sternomastoid muscle
89
foramen ovale
- opening in the atrial septum - closes within first hour after birth
90
ducus arteriorosus
- opening between the aorta and pulmonary artery - usually closes withing 10-15 hours after birth
91
pregnant female developmental considerations
- increaed blood volume by 30-40% - increased stroke volume and cardiac output - increased heart rate - decreased blood pressure
92
older adult developmental considerations
- increased systolic BP left ventricular wall thickens - heart rate unchanged at rest - cardiac output is unchanged at rest - decreased adaptation to exercise
93
chest pain assessment subjective data
- note onset, character, duration, symptoms, radiates, relieved by rest
94
dyspnea symptoms
- shortness of breath, paroxysmal, constant or intermittent, paroxysmal nocturnal dyspnea (sign of heart failure)
95
regional cardiovascular assessment order
1. pulse and BP 2. extremities 3. neck vessels 4. precordium
96
heave
- sustained forceful thrusting of ventricle during systole - indicates ventricular hypertrophy from increased workload
97
aortic valve location
- second right interspace
98
pulmonic valve location
- second left interspace
99
tricuspid valve location
- left sternal border
100
mitral valve location
- fifth interspace near the left midclavicular line
101
All Pigs Eat Too Much
1. Aortic 2. pulmonic 3. erb's point 4. tricuspid 5. mitral
102
splitting of s2
- normal physiological split that occurs during inspiration only in some peopel
103
fixed split
- a split that occurs in both inhale and exhale
104
parodoxical split
- occurs with exhale but not inhale
105
Patent ductus arteriosus (PDA)
- persistance channel between left pulmonary artery to aorta
106
atrial septal defect (ASD)
- abnormal opening in the atrial septum
107
ventricular septal defect (VSD)
- abnormal opening in the ventricular septum
108
tetrology of fallot
- right ventricular outflow obstruction - VSD - right ventricular hypertrophy - over riding aorta
109
heart failure symptoms
- dilated pupils, skin is pale/cyanotic, dyspnea, orthopnea, crackles, wheeze, cough, lower BP, nausea and vomiting, ascites, pitting edema, anxiety, declining o2sat, confusion, JVD, infarct, fatigue, tachycardia, enlarged spleen, lower urine output, weak pulse

Nursing (4 decks)

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