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Nursing > Health Assessment Test 2 > Flashcards

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
Q

doppler ultrasound stethoscope

A
  • used to detect a weak peripheral pulse
  • watch for presence of a swishing, whooshing sound which
  • indicates a pulse
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26
Q

chronic arterial insufficiency

A
  • deep muscle pain
  • pain with walking claudication
  • coolness, pallor
  • dimished pulse
  • thin, shiny skin
  • absence of hair
  • necrotic ulcers on toes, heels, laterla malleolus
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27
Q

chronic venous insufficiency

A
  • dull ache, heaviness in lower leg pain
  • pulses present
  • thick brawney, edematous skin
  • brown pigmintation
  • weeping ulcers on medial malleolus
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28
Q

chronic venous stasis

A
  • aching, heaviness, night leg or foot cramps
  • dilated, tortuous veins
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29
Q

acutre venous thrombosis

A
  • sudden onset pain
  • increased warmth, swelling, redness
  • watch for homan’s sign (not diagnostic)
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30
Q

homan sign

A
  • calf pain at dorsiflexion of the foot
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31
Q

pitting edema grading

A
  • 1+ mild
  • 2+ moderate
  • 3+ deep pitting
  • 4+ very deep pitting
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32
Q

lyphedema

A
  • nonpitting edema, unilateral, overlying skin is indurated and brawy
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33
Q

Raynaud’s syndrome

A
  • cause areas of the body like fingers and toes to feel numb and cold in response to cold temperatures
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34
Q

derived weight measures include

A
  • body weight as percent of ideal body weight
  • percent of usual body weight
  • recent weight change
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35
Q

body mass index

A
  • marker of optimal weight for height and indicator for obesity and protein-calorie malnutrition
  • weight/height(2) * 703
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36
Q

hemoglobin and hematocrit

A
  • indicators of iron status
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37
Q

cholesterol with triglycerides, LDL, and HDL levels

A
  • indicators of cardiovascular risks
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38
Q

marasmus

A
  • protein-calorie malnutrition
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39
Q

kwashiorkor

A
  • protein malnutrition
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40
Q

epidermis

A
  • replaced every 4 weeks
  • outermost layer
  • think but tough
  • houses keratin
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41
Q

dermis

A
  • inner supportive layer
  • consists of connective tissue
  • contains elastic tissue
  • nerves, sensory receptors, blood vessels, and lymphatics housed here
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42
Q

subcutaneous

A
  • adipose tissue
  • stores fat for energy
  • provides insulation for temperature control
  • cushions and protects
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43
Q

functions of the skin

A
  • 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
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44
Q

infants developmental care

A
  • languo (fine hair)
  • vernix caseosa (white, cheesy substance)
  • high risk for fluid loss
  • poor thermal regulation
45
Q

pregnancy developmental care

A
  • 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
Q

older adults developmental care

A
  • thin epidermis (low elasticity, high dryness)
  • less protective mechanisms (functioning decreases)
47
Q

skin conditions more prominent in African Americans

A
  • keloids, pigmentary disorders, pseudofolliculitis, melasma
48
Q

keloid

A
  • scars with increased height and weight
49
Q

pigmentary disorders

A
  • increased incidence of pigment problems
50
Q

pseudofolliculitis

A
  • razor bumps, razor burn, ingrown hairs
51
Q

melasma

A
  • patchy tan to dark brown discoloration of the face
52
Q

xerosis

A
  • excessive dryness
53
Q

seborrhea

A
  • excessive skin moisture
54
Q

nevus

A
  • mole
  • ABCDE
55
Q

pallor

A
  • white
  • anemia, shock, arterial insufficiency, anxiety, fear, exposure to cold, cigarette smoke
56
Q

erythema

A
  • redness
  • fever, local inflammation, blushing
57
Q

cyanosis

A
  • blue
  • lower perfusion, unoxygenated hgb
58
Q

jaundice

A
  • yellow
  • excessive billirubin, sclera, and hard and soft palate of mouth
59
Q

fear/anger

A
  • peripheral vasoconstriction
  • pallor
60
Q

embarrassment

A
  • facial/neck/flushing
  • erythema
61
Q

edema

A
  • accumulation of fluid in intercellular space
62
Q

cardiovascular system

A
  • contains the heart and blood vessels
63
Q

precordium

A
  • region on the anterior chest, over the heart and great vessels
64
Q

medaistinum

A
  • the middle third of the thoracic cavity between the lungs
  • contains the heart and great vessels
65
Q

base

A
  • top of the heart
66
Q

apex

A
  • bottom of the heart
67
Q

great vessels

A
  • superior and inferior vena cava
  • aorta
  • pulmonary veins
68
Q

atrioventricular valves

A
  • tricuspid and bicuspid (mitral)
69
Q

semilunar valves

A
  • pulmonic and aortic
70
Q

P wave

A
  • depolarization of the atria
71
Q

PR interval

A
  • from the start of the P wave to beginning of QRS
72
Q

QRS

A
  • depolarization of ventricles
73
Q

T wave

A
  • repolarization of ventricles
74
Q

QT interval

A
  • electrical systole of the ventricles
75
Q

s1

A
  • closure of the mitral and tricuspid valces
  • indicated beginning of systole
76
Q

s2

A
  • closure of the aortic and pulmonic valves
  • indicated beginning of diastole
77
Q

effect of respiration

A
  • 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
Q

s3

A
  • ventricular gallup
  • caused by ventricles being resistant to filling during the rapid filling phase (systolic heart failure)
  • heard right after s2
79
Q

s4

A
  • atrial gallup
  • present at the end of the diastole with resistance of the ventricles to fillling (diastolic heart failure)
80
Q

murmurs

A
  • results from turbulent blood flow caused by increased velocity, decreased viscocity, structural defects
81
Q

heart sounds described by

A
  • frequency or pitch
  • intensity or loudness
  • duration, late
  • timing
82
Q

preload

A
  • venous return
  • the volume of blood in the ventricle at the end of diastole
83
Q

frank-starling law

A
  • the greater the stretch, the stronger the cardiac contraction
84
Q

afterload

A
  • the resistance the heart has to pump against
85
Q

carotid arteries

A
  • lies between the trachea and the sternomastoid muscle
86
Q

jugular venous pulse and pressure

A
  • reflect the filling pressure and volume in the right side of the heart
87
Q

internal jugular

A
  • 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
Q

external jugular

A
  • more superficial
  • located lateral to the sternomastoid muscle
89
Q

foramen ovale

A
  • opening in the atrial septum
  • closes within first hour after birth
90
Q

ducus arteriorosus

A
  • opening between the aorta and pulmonary artery
  • usually closes withing 10-15 hours after birth
91
Q

pregnant female developmental considerations

A
  • increaed blood volume by 30-40%
  • increased stroke volume and cardiac output
  • increased heart rate
  • decreased blood pressure
92
Q

older adult developmental considerations

A
  • increased systolic BP
    left ventricular wall thickens
  • heart rate unchanged at rest
  • cardiac output is unchanged at rest
  • decreased adaptation to exercise
93
Q

chest pain assessment subjective data

A
  • note onset, character, duration, symptoms, radiates, relieved by rest
94
Q

dyspnea symptoms

A
  • shortness of breath, paroxysmal, constant or intermittent, paroxysmal nocturnal dyspnea (sign of heart failure)
95
Q

regional cardiovascular assessment order

A
  1. pulse and BP
  2. extremities
  3. neck vessels
  4. precordium
96
Q

heave

A
  • sustained forceful thrusting of ventricle during systole
  • indicates ventricular hypertrophy from increased workload
97
Q

aortic valve location

A
  • second right interspace
98
Q

pulmonic valve location

A
  • second left interspace
99
Q

tricuspid valve location

A
  • left sternal border
100
Q

mitral valve location

A
  • fifth interspace near the left midclavicular line
101
Q

All Pigs Eat Too Much

A
  1. Aortic
  2. pulmonic
  3. erb’s point
  4. tricuspid
  5. mitral
102
Q

splitting of s2

A
  • normal physiological split that occurs during inspiration only in some peopel
103
Q

fixed split

A
  • a split that occurs in both inhale and exhale
104
Q

parodoxical split

A
  • occurs with exhale but not inhale
105
Q

Patent ductus arteriosus (PDA)

A
  • persistance channel between left pulmonary artery to aorta
106
Q

atrial septal defect (ASD)

A
  • abnormal opening in the atrial septum
107
Q

ventricular septal defect (VSD)

A
  • abnormal opening in the ventricular septum
108
Q

tetrology of fallot

A
  • right ventricular outflow obstruction
  • VSD
  • right ventricular hypertrophy
  • over riding aorta
109
Q

heart failure symptoms

A
  • 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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