Midterm Flashcards
Review
What are the four basic techniques of physical assessment?
1) Inspection
*always the 1st technique utilized in every assessment
2) Palpation
* Utilized for assessing Tactile Fremitus
3) Percussion
*Used in assessing diaphragmatic Excursion
4) Auscultation
* technique utilized in assessing Bronchophony, Egophony, and Whispered Pectoriloquy
What technique is used to assess the lung tissue?
Indirect Percussion
What instrument is used to assess pulses when they cannot be palpated?
Doppler
What instrument is used to measure height?
Stadiometer
What instrument is used to assess for a fungal infection on the skin?
Wood Lamp
What instrument is used to measure the degree of joint flexion and extension?
Goniometer
What instrument is used to detect air, blood, fluid, or mass in body cavity?
Transilluminator
What are the skin layers?
1) Epidermis- Top Layer
2) Dermis- contains nerves, blood vessels and hair follicles
3) Subcutaneous- tissue followed by muscles and bones
Describe a Stage 1 Decubitus.
One layer of skin affected, reddened epidermis; skin intact, erythematous & non-blanchable
Describe a Stage II Decubitis.
Lesion involving the 2 layers of the skin, bleeding is observed; partial tissue loss
Describe a Stage III Decubitus.
A lesion involving 3 layers of the skin- epidermis, dermis, and subcutaneous tissues: Full-thickness loss, slough can be present.
Describe a Stage IV Decubitus.
A lesion involving 4 layers of the skin, epidermis, dermis, subcutaneous tissues, muscle and bone. Full-thickness tissue loss, eschar or dead tissue present.
Describe the grading of skin edema.
*Press around the bony prominences of the body with your 3 finger pads.
- Grade 0= no edema
-Grade 1+= 2 MM
-Grade 2+= 4 MM
-Grade 3+=6 MM
-Grade 4+=8 MM
What is the best technique for assessing skin turgor?
Pinch below the clavicles and below the wrist bilaterally
Describe anular lesion.
A lesion with one circle configuration
Describe a target lesion.
A lesion with concentric circles of colors inside a lesion with a dot in the center. This lesion is also know as the bullās eye, b/c of the dot at the center.
Describe a wheal lesion (AKA welt/ hive).
A lesion that is reddened, with irregular border caused by an insect bite or hive
Describe a macule.
A primary lesion, flat, there is a change in skin color, less than 1 cm. Example- freckles or petechiae chloasma.
Describe confluent
Lesions that are together
Describe a patch.
A type of macule that is more that 1 cm. An example of this; Mongolian spots, port-wine stain, vitiligo
Describe a vesicle or blister.
Primary lesion elevated, clear fluid round or oval with translucent wall less than 0.5 cm.
Example; chickenpox, poison ivy, and a small burn blister
Describe a Bullae
A type of vesicle lesion that is more than 0.5 cm.
Example; large burn blister
Describe a Port Wine Stain
A vascular lesion on the face that is flat, deep purple red and irregular shaped and deepens when a person cries or is highly emotional or exposed to high environmental temperatures. Typically, does not fade.
Describe Spider Angioma
A vascular lesion, flat, bright red dot with tiny radiating blood vessels ranging from pinpoint to 2 cm
Describe Hemangioma
A vascular lesion- bright red, raised 2-10 cm, does not blanch w/ pressure, usually present at birth and typically disappear at age 10
Describe a venous lake
A vascular lesion on the face, neck, ears, or lips usually common in 50 years old or older, soft, compressible, slightly elevated and ranges from dark blue to purple. Maybe due to sun exposure.
What skin variation can be found in a client with Cirrhosis of the liver?
Yellowish or jaundice due to the liver not functioning well and cannot get rid of bilirubin (bilirubin breaks down of hemoglobin and is excreted in bile.
Describe Tinea Pedis
Athleteās foot
Describe a keloid
A lesion that is elevated, irregular darkened area of excess scar tissue.
Describe ABCDE Criteria
*Criteria used to rule out malignancy lesion
A- asymmetry
B- Borders irregular
C- Varied Colors
D- Diameter more than 6 mm
E- Evolving Change
Describe Malignant Melanoma
Most serious type of skin cancer because it spread rapidly to the lymph & blood vessels, varied colors, irregular border and greater than 6 mm
Describe Kaposi Sarcoma
A painless malignant lesion, blue to purple, resembles keloid, most common in HIV positive patient
What is a black hairy tongue consistent with?
A fungal infection
Describe Leukoplakia
A whitish thickening of the mouth of HIV +client and cannot be scraped off
What are the predispositions or risk factors of skin cancer
Overexposure to UV light and genetic predisposition
Describe the order of occurrence of Herpes Zoster S/S:
1) Paresthesia (burning or tingling sensation)
2) Redness & Swelling
3) Vesicles/ Blisters
4) Weeping Blisters/ Vesicles
5) Crusted Lesion
6) Post-herpetic neuralgia- pain and burning sensations long after blisters disappear (cause of shingles or herpes zoster- chickenpox virus).
Describe Lanugo
Fine downy hair in newborn prominent on the upper chest, shoulders and back
Describe Mongolian Spots
Harmless purplish-blue spots on the sacral area that are usually common in darked skin infants. Disappears at age 3.
Describe Vernix Caseosa
Harmless white cheese like mixture of sebum and epidermal cells on the skin of the newborn baby. Disappears after several baths.
Describe Milia
Pimple like white heads on the nose or cheeks of the newborn which will disappear after 2-3 weeks
Describe vitiligo
Harmless white patchy, depigmented areas over the face, neck, hands, and skin folds of the newborn baby. It does not disappear
Describe Vellus Hair
Fine, pale short hair located all over the body, except lips, nipples, palms and soles of the feet
Describe Terminal Hair
Longer and coarser hair located on the eyebrows, scalp, axilla, legs, face and chest of males
What are the three Stages of hair growth cycles?
1) Anagen- growth phase (2-6 years)
2) Catagen- transitional phase ( 2-weeks)
3) Telogen- shedding phase (1-4 months)
What is the eccrine gland?
Sweat glands located all over the body that is made of water and salt
What is the apocrine gland?
Sweat glands made of water, salt, protein, and fatty acid located in the groin, axillary region and when mixed with bacteria, it smells musky.
Where are the sebaceous glands most predominant?
In the scalp area
What should be done to prevent the spread of infection?
Wash hands before and after each client encounter
What is the accurate assessment of jaundice in a dark skin person?
Inspection of the lips, oral mucosa, sclera, conjunctiva & palms
What is Tinea Pedis
Athleteās foot
What are the 10 locations of lymph nodes of the head and neck?
1) Preauricular
2) Postauricular
3) Occipital
4) Submental
5) Submandibular
6) Retropharyngeal
7) Deep Cervical Chain
8) Anterior Cervical Chain
9) Posterior Cervical Chain
10) Supraclavicular
How should the lymph nodes be palpated and what are the normal findings?
Gentle, circular motion and normal findings are non-palpable
When assessing for hearing loss, what is the most important question to ask?
If there are members of the
family with hearing loss because hearing loss has a familial tendency.
What examination is performed to assess the tympanic membrane and how should it appear?
An otoscopic examination, and the normal appearance is shiny pearly grey
What do white patches on the tympanic membrane indicate upon inspection with an otoscope?
A previous ear infection
Describe otitis externa
An ear infection of the external part of the ear. The ear may have redness, drainage, itching, with feverā¦but the tympanic membrane will still appear shiny pearly grey upon otoscopic examination.
Describe otitis media
An infection extending to the middle part of the ear involving the tympanic membrane, and the ossicles malleus, incus, and stirrup (stapes)
Describe Otitis Interna (AKA Labyrinthitis)
An infection, extending into the inner part of the ear (semi-circular canals, cochlea, and vestibular nerve). S/S; severe vertigo, a spinning world feeling, hearing loss, and ringing in the ears.
When assessing the ears of the patient, tenderness of the mastoid process will cause concern becauseā¦?
Any infection of the mastoid process can lead to brain infection
During and otoscopic examination, if the tympanic membrane is not visible, what steps should a nurse take?
1) Remove the otoscope
2) Reposition the auricle
3) Reinsert the otoscope
What are the four types of headaches?
1) Classic Migraine
2) Tension Headache
3) Cluster headache
4) Sinus Headache
Describe a classic migraine
A HA that is preceded by aura, floaters, and flashing lights.
Describe a Cluster HA
Several HAās over a period of days or months. Pain usually last for only a few minutes or hours, with a sudden onset.
Describe a tension HA
A HA that starts at the cervical area to the top of the head. May be unilateral or bilateral. Onset in gradual. Usually associated with stress.
Describe a sinus HA
A HA due to a sinus infection
What is hydrocephalus?
Enlargement of the babyās head due to inadequate drainage to the cerebrospinal fluid resulting in abnormal growth of the skull
What is craniosynostosis?
a premature closure of the sagittal and coronal sutures of the head of the baby resulting in altered head, face, and orbits.
What is fetal alcohol syndrome?
Exposure of the baby to high level of alcohol resulting in epicanthal folds, narrow palpebral fissures, deformed upper lip, and intellectual disability
What are the findings in a normal Rinne Test?
Air conduction is 2X greater than bone conduction
How do you conduct a Weber Test?
Place the activated base of the tunning fork at the midline of the skull
What is a normal Weber Test?
Sound vibration is equally heard on the right and left ear
What is an abnormal Weber Test?
The sound vibration goes to the defective ear
How do you test for balance?
The Romberg Test:
Conducted for 20 seconds, Pt. will be asked to stand erect with feet together, hands to the sides, closed eyes, support front/ back of the patient with your arms
What is a normal Romberg Test
No swaying or less than 2 inches
What is an abnormal Romberg Test?
Swaying more than 2 inches
What is confrontation?
Assessing for peripheral vision
What are the normal findings when assessing eyes for accommodation?
Pupils constrict and converge
What is Cover/ Uncover Test?
The preferred test for strabismus for children.
What are the normal findings for the 6 cardinal field of gaze?
No nystagmus or jerky movements of the eyes.
Describe Nystagmus
Jerky movements of the eyes, an abnormal finding during the 6 cardinal field of gaze
What is normal consensual response?
On transillumination, the pupils with direct light will constrict faster while the other eye will constrict sluggishly
What is the explanation for the Snellen Test grading?
Test grading of 20/30, you see at 20 feet what a person with normal vision will see at 30 feet
What is myopia?
Near sightedness, difficulty with far vision
What is hyperopia?
Far sightedness, difficulty with near vision.
What is Presbyopia?
Far sighted for people 45 years and older, difficulty with near vision
Describe dry eyes
Occurs with aging. S/S include redness, eyes feeling grainy, and burning.
What is macular generation?
The lost of central vision, but peripheral vision is still intact
Why should a patient with Acute Glaucoma be seen by the right away?
The patient can lose their vision within 1-2 hours
What is ectropion?
Lower eyelids are everted exposing the conjunctiva.
What is entropion?
The upper eyelid inverted into the eyes causing redness and irritation
What is a cataract?
A yellow dense lens due to the overexposure of dust and UV light
Describe Miosis
Pinpoint pupils, maybe unilateral or bilateral due to head injury, tobacco use, HTN drugs, Anti-psychotic drugs, and Glaucoma drugs.
Describe Mydriasis
Prolonged dilation of the pupils without any change in light. Pupils approximately 7 MM (normal size of pupils are 2-5 Mm, however, younger clientās pupils tend to be larger).
What are the causes of Mydriasis?
Migraine HA, Marijuana, Anti-cholinergic, Adrenaline, Cocaine, Amphetamines, and hallucinogens.
What is usually observed in a client with a brain injury?
Blown pupils or extensive Mydriasis
Describe Anisocoria
Unequal pupil size. Both pupils react to light but differ in size by 1 mm. It can be harmless. Cause- injury or lesion to the brain.
What are the true ribs?
Ribs 1-7
What are the false ribs?
Ribs 8, 9, 10
What are the floating ribs?
Ribs 11 and 12
Describe the Angle of Louie
Synovial joint articulated between the manubrium and the body of the sternum, in-line with the 2nd rib
How are the intercostal spaces named?
They are named after the rib above
What is the appropriate way to assess skin turgor in the elderly?
Pinch below the clavicle and below the wrist
How is jaundice assessed in a dark skinned person?
Inspect the lips, mucosa, conjunctiva, and palms
How is clubbing of the fingers assessed and what are the normal findings?
Bring the dorsal aspects of the fingers together with the corresponding finger to create a mirror image. Normal findings include a diamond space between the fingers with nail beds at 160 degrees.
What is the technique used to percuss the lungs and what are the normal sounds called?
Indirect percussion and Resonant Sounds
What is auscultation used for?
Technique used to assess bronchophony, egophony, and whispered pectoriloquy
What are the normal sounds on auscultation during whispered pectoriloquy?
Faint, muffled, and undistinguishable
What technique is used to assess for Tactile Fremitus?
Palpation
What are the causes of increased tactile fremitus?
1) Fluid in the lungs
2) Infection
3) Tumor
4) Fibrosis
What are the causes for decrease in Tactile Fremitus?
1) Soft Voice
2) Pleural Effusion
3) COPD
4) Obesity
5) Thick chest muscles
What is the technique used for Diaphragmatic Excursion, and what are the normal findings?
Percussion. Normal findings of 3-5 CM, in well-fit individuals 7-8 C.
What are the normal findings of Transillumination of the sinuses?
Red Glow
When will the sinuses not transilluminate a red glow?
When the sinuses are filled with fliud
What assessments should be performed for a patient complaining of a sinus headache?
Assess by transillumination and direct percussion of the sinuses
Normal sounds during bronchophony
Muffled sounds
What sounds are heard on auscultation using bronchophony when lungs are filled with fluid from bilateral Pneumonia?
Loud & Clear
Normal sounds during the auscultation of Egophony
āeeeeeeā
What is the location, sound, and ratio (inspiration: expiration) for tracheal?
Location: over the trachea
Sound: harsh, high-pitched
Ratio: I<E
What is the location, sound, and ratio (inspiration: expiration) for bronchial?
Location: Next to trachea, superior to each clavicle and also in the 1st ICS
Sound: Loud, high-pitched
Ratio: I<E
What is the location, sound, and ratio (inspiration: expiration) for bronchovesicular?
Location: Over the major bronchi
Sound: medium loudness, medium pitch
Ratio: I=O
What is the location, sound, and ratio (inspiration: expiration) for vesicular?
Location: Remainder of the lungs
Sound: Soft, low-pitched
Ratio: I>E
What sound will be heard upon percussion when air is trapped in the lungs?
Hyperresonant Sound
What is the expected adventitious sound heard on auscultation in a patient with lobar pneumonia?
Crackles
Describe Ronchi Sibilant or wheezing and what patient commonly has them
Adventitious breath sounds that are continuous high-pitched sounds, expected findings on auscultation of lungs for patient with Asthma
Describe Ronchi Sonorous & what patients commonly have them.
-Adventitious breath sounds that is low-pitched continuous snoring and rattling breath sounds.
-Common in Patients with:
+COPD
+Pneumonia
+Chronic Bronchitis
+Cystic Fibrosis
What are the normal findings on auscultation during whispered pectoriloquy?
The normal findings will be sounds that are faint, muffled, and indistinguishable
Describe Atelectasis
Decreased breath sounds of lobes of the lungs or collapsed lungs
Describe eliptical
Normal chest configuration for adults- lateral diameter is 2:1 with anteroposterior
Describe barrel chest
1) A normal chest configuration for infants, rounded
2) An expected variation for client with COPD & intercostal retraction
Describe scoliosis
Lateral deviation of the spinous process
Describe Kyphosis
Exaggerated curvature of the thoracic vertebrae- elderly
Describe Lordosis
Exaggerated curvature of the lumbar vertebrae- pregnant women
Describe Pectus Excavatum AKA Funnel Chest
Congenital deformity wherein there is depression of the sternum and adjacent cartilage, compressing the heart and lungs. Cardiac murmurs may be heard in severe cases, surgery is indicated
Describe Pectus Carinatum AKA Pigeon Chest
Congenital deformity forward displacement of the sternum with depression of the adjacent cartilage
Describe Tachypnea
RR over 20 per minute, rapid and shallow
Describe Hyperventilation
RR>20 per minute, rapid and deep
Describe Bradypnea
RR< 12 per minute, slow but regular
Describe hypoventialtion
RR< 12 per minute, slow but irregular and shallow
Describe Cheyne-Stokes
Periods of apnea but regular, common in elderly dying patients
Describe Biots/ Ataxic
Periods of apnea with irregular pattern observed in brain damaged patient
What is consistent with Intercostal contractions?
Labored breathing or SOB
What is the most important question to ask patient with rhinitis?
History of allergies
Where are most breast tumors located?
In the outer upper quadrant of the breast
When should a SBE be performed and by whom?
1) For elderly, advise to perform on the same time/ day every month
2) For a female still menstruating, advise to perform 3-5 days after menstruation when hormones are more stable
Describe fibroadenoma
Well defined breast tumor with no tenderness or discharge, most common in adolescent girls 15 years old to women up to 35 years old
Describe intraductal papilloma
Most common cause of benign nipple discharge (serous or bloody) in post-menopausal female
Describe Peau dā Orange
Orange peel appearance on the skin of the breast, which is a sign of malignancy or breast cancer
Provide examples of Therapeutic Comminication
1) Open-ended questions
2) Active listening
3) Lean toward the client
4) Eye Contact
5) Open posture
Provide examples of Non-Therapeutic Communication
1) WHY questions
2) Giving opinion
3) Giving advise
4) Close ended questions
5) False reassurance
What are some risks for hearing loss?
1) Occupation
2) Furosemide (Diuretic)
3) NSAID- Aspirin, Ibuprofen, Naproxen (anti-inflammatory)
What are examples for expected variations of COPD?
1) Barrel chest
2) SOB
3) Clubbing of fingers
4) O2 Saturation< 95%
What are some examples of expected findings of skin, hair, and nails?
1) Skin warm, dry, intact, pink undertone, even color, no scars, no lesion
2) Hair evenly distributed
3) Nails translucent, pick, with 160-degree nail angle
