Midterm Review Flashcards
What is subjective data?
This is the information the patient tells you about how they are feeling.
i.e. “I am feeling dizzy”
What is objective data?
The data that you get from lab results/tests, assessments or the chart.
i.e. patients blood pressure is 110/72
What are the 4 areas in a general survey assessment?
- Physical appearance
- Body Structure
- Mobility
- Behaviour
What are you assessing for in Physical Appearance area of general survey?
-do they look their stated age?
-Do they have usually sexual development for age?
-alert and oriented? responding appropriately?
- is there skin colour even tone? skin intact with no obvious lesions (describe their colour on the fitpatrick scale)
What are you assessing for in the Body Structure area of general survey?
Stature–height within normal range for age and genetic heritage
Nutrition–wt within normal range for ht and body build; evenly distributed body fat
Symmetry–body parts equal bilaterally and in relative proportion
Posture–standing comfortably erect as appropriate for age, normal “plumb line” through anterior ear, shoulder, hip, patella and ankle
Position–sitting comfortably? arms relaxed?
Body build–normal proportions (arm span=height, etc), no obvious deformities: note any congenital or acquired defects
What are you assessing for in the Mobility area of general survey?
gait–normal, base width-shoulder width; accurate foot placement; smooth, even and well-balanced walk; and presence of associated movements such as symmetrical arm swing
ROM–full mobility in each joint and deliberate, accurate, smooth and coordinated movement
What are you assessing for in the Behaviour area of general survey?
facial expression–maintaining appropriate eye contact and appropriate expressions to the situation
Mood and affect–cooperative with the examiner and responds appropriately to questions asked
Speech–clear and understandable articulation, as well as the following: fluent stream of talking, even pace, ideas are clear, word choice appropriate, communicating in native language easily or with interpreter
Dress–clothing appropriate for climate, culture and age group. Clean and fits the body.
Personal hygiene–appearance is clean and groomed for pt’s age, occupation, socioeconomic status, hair condition. Makeup appropriate for age.
What are the 3 levels of disease prevention?
Primary
Secondary
Tertiary
What is primary disease prevention?
people/populations are prevented from becoming ill, sick, injured in the first place. Promotion of health, prevention of illness (sanitization, immunization)
What is secondary disease prevention?
Early detection of disease, before symptoms emerge (screening tests such as mammography, lipid profiles, pap tests, etc)
What is tertiary disease prevention?
Prevention of complications when condition/disease is present/has progressed (foot care for diabetic patients, risk factor teaching on how to avoid complications post cardiac surgery)
What does ADPIE stand for and describe each step.
Assessment–Collect, organize, validate & document data
Diagnosis (Nursing)–Analyze data, identify health problems, risks & strengths, formulate diagnostic statements
Planning–Prioritize problems and diagnoses, formulate goals and potential strategies.
Implementation–Reassess the pt, implement nursing interventions, supervise delegated care, document nursing activities
Evaluation–Collect data related to outcomes, complete data with outcomes, relate nursing actions to patient goals/outcomes, draw conclusions about problem status, continue/modify or end the patients care plan
What are the 4 assessment techniques?
Inspection–visual; rash, redness, etc
Palpation–feeling/touching for underneath the skin; heat, lumps, swelling and tenderness
Percussion–trying to feel for different sounds/vibrations, sound around organs may indicate air filled, fluid filled, or bone
Auscultation–listening to the sounds of body using a stethoscope
What does febrile mean?
describes a temperature of 38.4 or higher
What does pyrexia mean?
Medical term for fever
What is the medication for fever called?
Antipyretic
What is the generalized purpose of the 60 second check?
To ensure your patient is safe and not in distress
-ABC’s
-Tubes/lines/dressings
-Respiratory equipment
-Patient safety
-Environmental safety
-Sensory (odors, smells, etc)
What is the normal range for temperature?
35.8-37.3 degrees celcius (oral)
What is the normal range for pulse?
radial pulse between 60-100
What is the normal blood pressure?
> 120/80
What is the normal range of respirations?
10-20 breaths per minute
What is the normal range for oxygen saturations?
O2 sat: 95 or higher
What are the 4 things we are assessing when we check the pulse?
Rate
Rhythm
Force
Equality
How long do we count when measuring regular and irregular breaths?
30 seconds for regular, 60 seconds for irregular
What is force (in relation to heart rate) and how do we assess it on a scale?
shows the strength of stroke volume (how much blood is pumped out of the heart during each beat)
0 absent
1+ weak, thready
2+ normal
3+ full, bounding
What is bradycardia and tachycardia and how do we distinguish them from normal?
Bradycardia is a slow heart rate of 60 beats or less
Tachycardia is a fast heart rate that is over 100
What part of our brain regulates temperature?
the hypothalamus
What is the SA Node referred to/nickname and where is it located?
The main Pacemaker of the heart
located in the right atrium
A patient has shortness of breath which occurs when lying flat. What is this called?
Orthopnea
Describe cardiac output and the factors that influence it.
Cardiac output is the amount of blood the ventricles push out of the heart per minute.
This is affected by both heart rate and stroke volume, since CO= HR x SV
Heart rate is the amount of beats per minute and stroke volume is the amount of blood pumped out the ventricles per stroke.
What is peripheral vascular resistance and give some examples.
this is anything working against the blood flow through your arteries.
Ex. Elasticity of vessel walls (how much they can extend and recoil), diameter of the arteries (more diameter increase flow but decreases pressure), viscosity or thickness of the blood (thicker blood takes more effort to push through so more pressure)
What is hypotension and hypertension and how do we separate them from normal blood pressure?
hypotension is a systolic blood pressure of less than 90 mm Hg, or a fall of more than 20% from normal blood pressure
Hypertension is a systolic blood pressure of greater than 140 mm Hg
What is orthostatic hypotension?
- blood pressure drops suddenly after standing up/changing positions
- This happens from abrupt peripheral vasodilation without a compensatory increase in cardiac output
- systolic drops > 20 mm Hg or pulse rate > 20 bpm
- Those at risk are: people of high blood pressure meds, older adults, heat exposure, those on bed rest
After one reading of high blood pressure, would the patient be diagnosed with hypertension? why?
No. There are many factors that could affect the blood pressure readings such as:
- caffeine intake
- recent exercise
- wrong blood pressure cuff size
- error on machine readings
- anxiety or stress
Most likely the person would be asked about their caffeine, exercise and anxiety levels and if the machine is suspected as the problem, they might do manual testing, use a different cuff size or the other arm to confirm.
What are some functions of the skin?
- protection
- temperature regulation
- wound repair
- perception
- penetration prevention
- identification
- absorption and excretion
- production of Vitamin D
- communication
What does sebaceous mean in relation to hair?
produces lipids (sebum) substances. This is found in our hair follicles when sebaceous glands secrete sebum, which is an oily substance that protects the skin from drying out
Who determines the unacceptable pain levels during the OPQRSTUV assessment?
The patient does
The unacceptable pain level is asking a patient what level of pain they are okay with living with.
Specifically, for someone who is in chronic pain, normally at a 10 level, they might be determine their unacceptable level is 4. Meaning they could live with a 1-3 level pain.
What does OPQRSTUV stand for?
Onset
Provocative/Palliative
Quality
Region
Severity
Timing/Treatment
Understanding
Value
What is ecchymosis?
Bruising
What is a macule?
A flat, circumscribed, colour change in skin, that is less than 1 cm
What is a papule?
an elevated, solid, circumscribed, less than 1 cm
In reference to moles
Describe psoriasis.
flakey, scaly (shredding of keratin cells), type of dermatitis, that is autoimmune
What does ABCDE stand for in relation to moles and describe each step.
Asymmetry (is it symmetrical? or oddly shaped?)
Border (does it have a destinct borer or is it blurred, or spikey?)
Colour (is it the same colour throughout? Changed colour?)
Diameter (is the diameter less than 6 mm?)
Elevation/evolution (is it raised up from the rest of the skin? has it grown?)
clubbing of the nails is seen with which health conditions?
Congenital cyanotic heart disease
What are some suggestions you could teach someone on healthy habits for skin?
using sunscreen
wearing a hat
wearing thin, covering clothing
avoiding tanning beds
using lotion
limit sun exposure
Name the 4 valves and locations of the heart.
Tricuspid valve–between the right atrium and right ventricle
Mitral valve–between the left atrium and ventricle
Aortic valve–between the left ventricle and aorta
Pulmonic valve–between the right ventricle and the pulmonary trunk
Systole is the _________ of the heart, diastole is the ___________ of the heart
contraction, relaxation
What part of the cycle would you be listening to when you hear S1 sounds?
the beginning of systole (contraction of the ventricle)
What part of the cycle would you be listening to when you hear S2 sounds?
During diastole (relaxation)
We hear heart sounds when a valve closes, so in this case, we heard it when the SL valves close during the isovolumetric relaxation stage.
Right after the heart has contracted and ejected blood. Some of the blood tries to fall back into the ventricles from the trunk and aorta and this casues the valves to close, making the S2 sound.
What would produce a swooshing sound in the artery? Is this normal?
a bruit (bru-ee)
caused by turbulent blood flow in the artery. A potential blockage that could become dislodged on palpation and cause a blood clot to travel (stroke, pulmonary embolism)
Describe what a thrill it. Is it a normal sounds to hear?
a palpable vibratory sensation felt on the skin, usually over a blood vessel or the heart
Indicating turbulent flow and is generally not considered normal
What are the locations and names of the 5 places we auscultate the heart?
Aorta area - 2nd intercostal space right sternal border
Pulmonic area - 2nd intercostal space left sternal border
Erb’s point - 3rd intercostal space left sternal border
Tricuspid valve - 5th intercostal space left sternal border
Mitral valve - 5th intercostal space mid clavicular line
Distinguish the components of a holistic health history
Biographical data
Reason for seeking care
Current health or history of current illness
Past medical history
Family history
Review of systems
Functional assessment
What are the 4 components influencing the 5 percussion notes?
Amplitude
Pitch
Quality
Duration
What does amplitude mean?
intensity
loudness or softness of a sound
what does pitch mean?
frequency
the # of vibrations per second
what is a basic principle that is helpful to apply to production of sound/percussion?
A structure with more air (lungs) produces louder, deeper and longer sound because it vibrates freely; whereas a denser structure (bone or organs) gives a softer, higher and shorter sound as it vibrates less easily
Describe resonance and where do we normally hear it?
Resonance is a medium-loud and low pitch sound that is clear and hollow
We hear this when percussing during the respiratory system assessment, and it’s good
This is the proper sound because the lungs are filled with air–sound different from other organs or bone.
What is the purpose of a general survey?
It’s a study of the whole person, covering the general health state and any obvious physical characteristics
Should give an overall impression, or quality/character of the patient as a whole
Objective data
what are some general questions you should ask yourself during a 60 second check?
What data leads you to believe there is a problem with ABC’s?
If a problem, is it non urgent or urgent & needs immediate action?
Does anyone need to be contacted?
Is the person safe?
Is there tubes/lines/dressings intact and properly sitting?
How much higher is the rectal temperature in comparison to the normal oral temp of 35.8-37.3?
The rectal temp is 0.4-0.5 degrees higher than the oral
What is the normal axillary temperature in comparison to normal oral temp?
axillary/armpit temp is 0.6 degrees lower than oral temp
List some common things that might cause a decreased temperature?
-Newborn/older adult
-Weather
-What did they eat? something cold?
-Medications
When is blood pressure the lowest?
In the morning
What is the difference between kyphosis and lordosis?
kyphosis is a spinal condition that is distinguished by abnormal rounding or bowing of the upper back, resulting in a hunchback position
Lordosis is excessive inward curvature of the cervical and lumbar region of the spin
What function does the lymph nodes have as a part of the immune system?
they filter substances that travel through the lymphatic fluid, and they contain lymphocytes that help the body fight infection and disease
Enlarged lymph nodes are called?
Lymphadenopathy
Blood pressure is determined by 5 factors. What are they? Describe them.
- cardiac output (the amount of blood pumped out of the ventricles per minute)
- Peripheral vascular resistance (opposition to blood flow–smaller vessels need greater BP to push blood)
- Volume of circulating blood (increased volume = increased pressure)
- viscosity (thickness of blood)
- Elasticity of vessel walls (if rigid, more pressed needed to push blood through)
What are the 3 normal breath sounds heard during respiratory assessment?
Bronchial
Bronchovesicular
Vesicular
What does bronchial sound like?
High pitched and loud
louder and longer during expiration
Heard in the trachea (neck)
What does bronchovesicular sound like?
loud and medium pitched
equal during inspiration and expiration
Heard in the upper intercostal, more medial (towards the sternum)
What does vesicular sound like?
soft, low pitched
mostly heard during inspiration
Heard over the peripheral lung field (almost in a vest shape, inferior part of lungs and the lateral side of both lungs)
What is the difference between the bell and diaphragm sounds heard through the stethoscope?
Diaphragm–functions best for high frequency sounds (lung sounds, heart sounds, bowel sounds)
Bell–Functions best for low frequency sounds (murmurs, bruits, and abnormal heart sounds)
What is afterload?
Is the opposing pressure that the ventricle must generate to open aortic valve against the higher aortic pressure (basically the resistance against which the ventricle must pump its blood)
What is preload?
The venous return that builds during diastole
It is the length to which the ventricle muscle is stretched at the end of diastole just before contraction
Describe what a murmur is?
some conditions create turbulence in blood flow and collision currents, these result in a murmur (swooshing sound)
What is S3?
Normally diastole is silent, but sometimes ventricular filling creates vibrations that can heard over the chest
What is S4?
This occurs at the end of diastole, when the ventricle is resistant to filling.
The atria contract and push blood into a noncompliant ventricle, this creates vibrations.
What is the cardiac cycle?
The rhythmic movement of blood through the heart
Has 2 phases: Systole and diastole
What is systole?
the hearts contraction, blood is pumped from the ventricle and fills the pulmonary and systemic arteries
1/3 of cardiac cycle
What is diastole?
The ventricles relax and fill with blood
2/3 of the cardiac cycle
What is myocardium?
the muscular wall of the heart, it does the pumping
What is endocardium?
The thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves
What is the precordium?
The area on the anterior chest overlying the heart and great vessels
What is the mediastinum?
Is the central compartment of the thoracic cavity, located between the lungs
What is erythema?
An intense redness of the skin from excess blood in the dilated superficial capillaries
What angle should a healthy nail bed be at?
160 degrees celsius
A nodule is….
A solid, elevated, hard or soft, > 1 cm diameter
may extend deeper into dermis than papule
A cyst is..
A encapsulated fluid-filled cavity in dermis or subcutaneous layer
tensely elevating skin
An annular is…
Also called circular, begins in centre and spreads to periphery
What is the name for lesions that merge together?
Confluent
What is the subcutaneous layer of skin?
Beneath the dermis layer
Made up of adipose tissue, which is made up of lobules of fat cells
Stores fat for energy, provides insulation for temp control and aids in protection by its soft, cushioning effect.
What are some characteristics of epidermis layer of skin?
Outer layer, highly differentiated
Thin but tough
Cells are tightly bound together into sheets that form a rugged protective barrier
Major ingredient is keratin
The melanocytes produce the pigment melanin, which gives skin and hair their brown tones
What are some characteristics of dermis layer of skin?
The inner supportive layer consisting mostly of connective tissue, or collagen
This layer is the tough fibrous protein that enables the skin to resist tearing
Has elastic tissues that allow for stretch with movements
Nerves, sensory receptors, blood vessels, and lymphatic vessels lie in the dermis
Describe acute vs chronic pain?
Acute pain is short term and self limiting, it typically goes away after an injury heals (Surgery, broken leg, kidney stones)
Chronic pain has been present for 6 months or longer than the time of expected tissue healing (bone cancer, diabetes, long term back pain)
What is referred pain?
pain that originates in one location but is felt at another site
specialized nerve endings, called _________ detect painful sensations from the periphery and transmit them to the Central Nervous System (CNS)
Nociceptors
What does OPQRSTUV stand for and what does each step mean?
- Onset–when did the pain start?
- Palliative/provocative–does it
increase with movement/activity? Are the symptoms relieved with
rest? Were any previous
treatments effective? - Quality–what does your pain feel like? What words describe your pain?
- Region–where is your pain? Does the pain radiate, or move to other areas?
- Severity–how would you rate your pain on an intensity scale?
- Timing/treatment–what treatments have worked in past? Is it constant, dull or intermittent?
- Understanding–what do you believe is causing the pain?
- Value–what is your acceptable level for this pain? Is there anything else you would like to say about your pain? Are there any other symptoms related to pain?
What do we use to find out someone’s oxygen saturation (SpO2)?
The pulse oximeter on the vitals machine
What is the normal reading for O2 saturation?
higher than 95% (90-95% is adequate)
What is a concerning level for O2 saturation?
80-85% is significantly low and anything lower than that is at risk of respiratory arrest
What is a acceptable level for a COPD patient for O2 Saturation?
88-92%
What are some changes that might be noted in the vital signs of elderly people?
BP may be increased (but we would like it to be below 150/90)
Pulse may be lower
Temperature may be lower
What causes lower O2 saturations?
- Respiratory issues (asthma, COPD, etc)
- Heart issues
- Shock
- Hyperventilating
- Having cold fingers
What is wheezing?
high, pitched, musical sound
air going through narrowing airways
can be heard with COPD
What do crackles sound like?
fine, higher pitched and soft, mostly heard in small airways and alveoli
can be lower pitched and louder sounding
Bubbling or gurgling sound
What are some changes in the lungs and thorax that might happen in the elderly?
- costal cartilage calcify (less mobile)
- respiratory muscle strength declines
- Lungs less distensible (less recoil)
- lungs more rigid and harder to inflate
- increase in small airway closure
- diminished surface area for gas exchange
Why would someone have a barrel chest?
It can indicate an underlying condition such as COPD.
The lungs become over expanded with air (but they cannot breath out all the air), causing the ribs to stay expanded.
This is why we check for the rib angles during our respiratory assessment, because it is a major sign of COPD*
