NURS 301 1st exam Flashcards
1
Q
what guides an assessment
A
questions which give you the subjective about the patient
2
Q
episodic health assessment
A
usually done when a patient is following up with a healthcare provider for a previously identified problem. usually once a year
3
Q
screening health assessment
A
example would be diabetes
4
Q
what percent of an adult body weight is skin?
A
16% heaviest organ of our body
5
Q
control mechanisms of the skin
A
thermoregulation and fluid electrolyte balance
6
Q
what vitamin does the skin produce
A
vitamin D
7
Q
integumentary system can provide vital information on
A
patients health status and whether the functioning of the total body system if adequately performing
8
Q
pruritus
A
itchy skin
9
Q
OLDCARTS
A
onset, location, duration, characteristics, aggravation or alleviation, related systems, treatment by the patient, severity
10
Q
IPPA
A
inspection, palpation, percussion, auscultation
11
Q
perspiration is normal on
A
face, hands, axillae, and skin folds
12
Q
what do you test during skin assessment
A
skin texture, skin thickness, edema
13
Q
skin texture
A
check smoothness/firmness and elasticity
14
Q
edema
A
can be pitting or non-pitting. best place to assess is the tibial plate
15
Q
questions to ask when assessing edema
A
Did your shoes fit okay today? do your legs feel swollen?
16
Q
inspect the skin surfaces for
A
skin breakdown on bony prominences, lesions, tattoos, scars, rashes, bruising
17
Q
ABCDEF format
A
asymmetric, borders, colors, diameter, elevation, and feeling
18
Q
when assessing skin conditions always describe using
A
ABCDEF format
19
Q
Braden skin scale
A
tool that is used to determine a patients risk in developing a pressure ulcer. based off 6 criteria: sensory perception, moisture, activity, mobility, nutrition, friction and shear
20
Q
scoring with Braden scale
A
each category is worth 1-4 except friction and shear which is 1-3. 15-18=mild risk, 13-14 = moderate risk, 10-12.= high risk, and less than 9 = very high risk
21
Q
populations at risk for pressure ulcers
A
people in casts or cervical collars, immobilizing devices, nasal cannulas, wound vacs, any drains
22
Q
stage 1 pressure ulcer
A
purple/maroon discolored area/blood filled blister. the skin remains intact, nonblanchable redness
23
Q
stage 2 pressure ulcer
A
partial thickness loss of dermis, looks like an open blister, no slough
24
Q
stage 3 pressure ulcer
A
full thickness tissue loss, fat may be visible but not bone or tendon, can include undermining or tunneling
25
stage 4 pressure ulcer
full thickness loss with exposed bone, tendon, or muscle. slough or eschar can be present. high risk of osteomyelitis
26
unstageable pressure ulcer
full thickness tissue loss in which the base of the ulcer is covered in eschar, slough, or both. eschar has to be surgically removed unless on heal
27
common areas of skin breakdown supine position
occiput, scapula, sacrum, heels
28
common areas of skin breakdown lateral position
ear, acromion process, elbows, trochanter, heels
29
skin tears
skin separation between dermis and the epidermis that occurs due to a traumatic event
30
skin tear documentation
should be documented separate from pressure wounds as they are a result of acute, traumatic injury
31
populations at risk for skin tears
older adults, compromised nutrition, fluid volume deficit, edema, confusion, limited mobility, lack of independence, or bruised skin
32
skin turgor
a measure of skin elasticity and hydration status. normal results in less than 4 secs. more than 6 seconds = skin tenting
33
annular
ringed with clear center
34
linear
straight line (streak)
35
circinate
circular
36
confluent
lesions run together
37
discrete
individual/distinct
38
discoid
disk shaped without central clearing
39
zostiform
linear cluster along the nerve root
40
generalized
widespread
41
macule
color change, flat, less than 1 cm Ex: freckles
42
papule
something you can feel, less than 1 cm Ex: mole
43
plaque
papule which merge together. wider than 1 cm Ex: psoriasis
44
patch
macule that are larger than 1 cm Ex: birthmark?
45
nodule
solid, elevated, larger than 1 cm
46
wheal
superficial, raised, transient, slightly irregular, due to edema Ex: mosquito bite
47
urticale
hives
48
tumor
firm, soft, deeper into dermis, larger than a few cm
49
vesicle
elevated cavity containing free fluid ex: chx pox
50
postule
pus filled cavity, elevated Ex: acne
51
bulla
superficial in epidermis, thin walled, ruptured easily, ex: blister
52
cyst
encapsulated fluid filled cavity in dermis or subcutaneous layer.
53
fissure
linear cracks with abrupt edges. extends into the dermis
54
excoriation
from scratching, self inflicted abrasion
55
erosion
scooped out but shallow. superficial but no bleeding
56
lichenification
prolonged intense scratching eventually thickens the skin and produces tightly packed sets of papules
57
keloid
a hypertrophic scar with excess scar tissue. looks smooth, rubbery, and claw like
58
purpura
occurs when small blood vessels join together or leak blood under the skin
59
petechiae
when pupura spots are very small
60
ecchymosis
large purpura, bruising. look for multiple areas at different stages could be sign of abuse
61
risk factors of skin cancer
HPV, alcohol intake, genetics, age, Male gender, long term skin inflammation, smoking, moles, fair skin, chemical exposure
62
basal cell carcinoma
most common, starts as skin colored papule and grows slowly
63
squamous cell carcinoma
red scaly with sharp edges. develops central ulcer with redness. grows rapidly
64
melanoma
very aggressive. originates in the melanocytes. most are brown but can be other colors. kills about 1 person an hour
65
first degree burn
superficial
66
second degree burn
superficial partial thickness
67
third degree burn
deep partial thickness
68
fourth degree burn
full thickness
69
5th and 6th degree burns
lethal and found during autopsy
70
vellus hair
short, fine, relatively unpigmented, covers most of the body
71
terminal hair
coarser thicker and usually pigmented. scalp, eyebrows, pubic hair, axillae, legs
72
total body hair assessment
color, texture, distribution, amount/quantity, hygiene, lesions/parasites, dandruff, odor
73
nails
hard transparent plates of keratinized epidermal cells
74
nail assessment
shape, consistency, thickness, texture, attachment, color
75
nail shape and contour
looking for clubbing, spooning, jagged, longitudinal grooves, pitting, paronychia, hygiene, biting
76
clubbing
congenital or smoking. late sign of bad perfusion to peripheral extremities
77
spooning
concave curves - iron deficiency
78
jagged
chronic anxiety
79
longitudinal grooves
normal
80
pitting
from psoriasis
81
paronychia
infection of the nail folds
82
greying of hair
decrease in melanocytes
83
what are you looking at when looking at a persons vital signs
trends
84
vital signs
temp, pulse, respirations, BP, 2nd: O2 saturation and sometimes pain
85
when do you take vital signs
clients admission to facility, before and after surgery, changes in physical condition, before and after medication, when ordered, during blood transfusion, before and after nursing interventions
86
body temperature
heat produced - heat lost = body temp. normal temp is 96.8-99 F
87
99-100
low grade fever
88
fever
hyperthermia - greater than 100.4. response to infection
89
we have an issue if temp is greater than
102
90
rectal temp is
1 degree greater than oral
91
axillary temp
1 degree lower than oral
92
tympanic temp
equal to oral temp
93
hypothermia
skin temp below 95 F. caused by prolonged exposure to cold
94
pulse is an indicator of
circulatory and respiratory status
95
sites for obtaining a pulse
radial, apical, brachial, popliteal, dorsalis pedis, carotid, temporal, femoral, posterior tibial
96
Rate characteristics
normal - 60-100
bradycardia - less than 60
tachycardia - greater than 100
97
rhythm
can be regular, regularly irregular, or irregularly irregular
98
quality of pulse
weak, thready, bounding
99
respiration
bodys mechanism for exchanging gases. two components: inspiration and expiration. usually 1:2
100
ventilation
the movement of gases in and out of the lungs
101
diffusion
movement of oxygen and carbon dioxide between the alveoli and red blood cells
102
perfusion
the distribution of red blood cells to and from the capillaries
103
normal respiratory rates
```
newborn - 30-60
infant - 30-50
toddler - 25-32
child - 20-30
adolescent - 16-19
adult - 12-20
```
104
normal tidal volume
500cc
105
inspiration
diaphragm contracts
106
expiration
diaphragm relaxes and abdominal organs return to normal position
107
sigh
physiological mechanism for expanding small airways and alveoli not ventilated during a normal breath
108
blood pressure
force exerted on the walls of an artery by the pulsing blood under pressure from the heart. moves from area of high pressure to area of low pressure
109
systolic pressure
peak of maximum pressure occurring with ejection
110
diastolic pressure
minimal pressure exerted against the arteries at all times
111
pulse pressure
the difference between the systolic and diastolic pressure
112
normal BP
120/80
113
high BP
hypertension - greater than 140 = stage 1, greater than 160=stage 2, greater than 180=stage 3, greater than that hypertensive crisis
114
low BP
hypotensions 90/60
115
orthostatic hypotension
occurs when person develops low blood pressure with raising to an upright position
116
factors influencing blood pressure
age, anxiety, ethnicity, gender, diurnal variation
117
why are vital signs important?
indicators of the body's status, response to stressors, provides parameters for monitoring status and progress, and provides parameters for nursing interventions
118
exchange of gases is influenced by
central nervous system, cardiovascular system, musculoskeletal system
119
autonomic mechanism of respiration is triggered where?
in the pons and medulla oblongata of the brain stem
120
upper respiratory tract
nose, mouth, sinuses, pharynx, larynx, and upper trachea
121
lower respiratory tract
lower trachea, bronchi, and lungs
122
vertical lines along the anterior chest
anterior axillary line, midclavicular line, midsternal line
123
vertical lines along the posterior chest
scapular line and vertebral line
124
vertical lines along the lateral side of chest
anterior axillary line, midclavicular line, and posterior axillary line
125
diaphragm does what during inhalation and exhalation?
contracts and flattens for inhalation (allows air to passively move in) and curves back to normal for exhalation
126
how to calculate pack years
pack per say X years they have smoked
127
cystic fibrosis
mucus producing cells always secreting
128
COPD
chronic obstructive pulmonary disease. results in less air that continuously flows in and out of the airways
129
pursed lips and nasal flaring
indicative with COPD
130
precuts excavatum
congenital posterior displacement of lower aspect of sternum. this gives the chest a hollowed out look
131
barrel chest
associated with emphysema and lung hyperinflation. increased transverse to AP diameter as well as diaphragmatic flattening
132
kyphosis
causes the patient to be bent forward.
133
scoliosis
condition where the spine is curved to either the left or right
134
what is the most important part of the respiratory assessment
assessing air flow
135
larger airways sound
louder and coarser
136
smaller airways sound
softer and finer
137
identify breath sounds by listening for
intensity, quality, pitch, and duration of inspiration and expiration
138
vesicular breath sounds
soft, low pitched, found over fine airways and near sites of air exchange
139
bronchovesicular breath sounds
found over major bronchi that have fewer alveoli
140
bronchial breath sounds
loud high pitched and found over the trachea and larynx
141
auscultate how many spots anteriorly and how many posteriorly
6 anteriorly and 8 posteriorly
142
adventitious sounds of the lungs
crackles or rales, rhonchi, wheezes, pleural friction rub
143
rhonchi
low pitched continuous sounds. similar to wheezes. imply obstruction of the larger airways
144
adventitious sounds during percussion
hyper resonance (sign of emphysema), dull sounds (signs of fluid, pneumonia, or mass), or no sound present
145
if you hear an abnormal sound what should you do?
have the patient cough and listen again
146
palpate for crepitus if..
patient has rid fractures, recent surgery, chest tubes, or trauma
147
expected findings of bronchophony
sounds should be muffled, is sounds are clear can indicate consolidation
148
during percussion, healthy lungs should have __ sounds
resonant
149
factors for COPD
elastic quality of airways and air sacs are gone, damage of the walls between the air sacs that cause chronic thickness and inflammation, the existence of mucus which blocks the airways
150
COPD can include all or just one of which of the following
emphysema, bronchitis, asthma
151
expected expiration ratio
expiration twice as long as inspiration 1:2
152
physical exam findings with COPD
hyperresonance, decreased chest exclusion, decreased fremitus, dyspnea, pallor, pursed lip breathing
153
number one contributor to COPD
smoking
154
asthma
allergy triggers inflammation and restriction in airways. chronic condition but has acute attacks
155
what is a good indicator of someones control of their asthma
the amount of rescue meds used
156
physical exam findings with asthma
tachypnea, tachycardia, retractions, wheezing, hyper expansion of the thorax
157
physical exam findings of pneumonia
SOB, fever, decreased breath sounds, increased pulse, cough, phlegm, pain in chest, decreased SaO2
158
atelectasis
consolidation and closing of small airways. will have decreased breath sounds in the bases
159
pleural effusion
fluid in pleural space
160
pneumothorax
air in pleural space - can cause tracheal deviation to good side
161
hemothorax
blood in the pleural space
162
perfusion
blood distribution
163
ischemia
lack of blood flow to tissue
164
shock
decrease perfusion systemically
165
what can effect perfusion
nutrition, metabolism, motion, tissue integrity, intracranial regulation, elimination, pain, oxygenation
166
what happens when cells are without oxygen
they go into anaerobic metabolism
167
base of the heart
widest part
168
apex of the heart
point at the bottom
169
arteries
take oxygenated blood away from the heart to the organs and tissues
170
veins
take deoxygenated blood back to the heart
171
sinus rhythm
normal heart beat 60 - 100 bpm
172
SA node
body natural pacemaker
173
AV node HR
40-60
174
bundle of his HR
20-40
175
purkinje fibers HR
20
176
electrical condition of the heart
SA node, AV node, bundle of his, purkinje fibers
177
S1
Systole. contraction of the ventricles. Lub sound. ejects blood to the heart and body.
178
S2
Diastole. relaxation of the ventricles. dub sound.
179
what is going on during systole
mitral and tricuspid valves are closing
180
what is going on during diastole
pulmonic and aortic valves are closing
181
exception to direction of arteries and veins
pulmonary vein and artery
182
major arteries of the arm
brachial, radial, ulnar
183
major arteries of the leg
femoral, popliteal, dorsalis pedis, posterior fibial
184
types of veins
deep, superficial, and perforated
185
major arteries of the heart
ascending aorta, descending aorta, and abdominal aorta
186
major veins of the heart
superior vena cava and inferior vena cava
187
how do veins differ from arteries
veins do not have pressure to propel blood forward, they are a low pressure system, one way valse only, utilize muscular contraction in order to propel blood forward, and are large in diameter
188
arteries are
smaller than veins and have a force to bring blood to organs
189
head and neck veins
internal and external jugular veins
190
internal and external jugular veins function
to return blood back to the heart from the head and neck through the superior vena cava
191
chronic illnesses to ask about with heart assessments
DMII, renal failure, COPD, CHF, HTN, arterial fibrillation, elevated cholesterol, MI, angina, CAD, PVD
192
CABG
coronary artery bypass graft
193
DMII
diabetes mellitus - bad for vessels and heat
194
CHF
congestive heart failure
195
HTN
hypertension
196
angina
pain
197
current complaints to ask about with heart assessment
chest pain, SOB, cough, nocturia, fatigue, fainting, swelling of the extremities, leg pains or cramps
198
tachycardia
HR above 100 bpm
199
bradycardia
HR below 60
200
what do you do if there is a irregular HR
may indicate arrhythmia. check if an apical/radial pulse deficit exists
201
how to check apical radial pulse
count apical pulse and radial pulse (hopefully at same time using two nurses) Apical - radial = deficit
202
why do we do the apical radial pulse?
if apical pulse is higher than radial it can reflect insufficiency and that the heart is too weak to send blood to arteries
203
grading of pulses
```
0+ - absent
1+ - diminished, barely there
2+ - normal
3+ - full volume
4+ - bounding (forceful)
```
204
if pulse is absent what is your next course of action
assess for level of consciousness and call for help
205
factors affecting heart rate
age, gender, body size, BP, medications, exercise, diet, sleep, anxiety
206
pulse pressure
the pressure difference between the systolic and diastolic pressure. normal is 30-40
207
what can high BP lead to
stroke
208
what do you use the diaphragm of your stethoscope for? what about the bell?
high pitched sounds
| bell - low pitched sounds
209
bruit
abnormal finding. blowing sound. usually means plaque and narrowing
210
peripheral neuropathy
Weakness, numbness, and pain from nerve damage, usually in the hands and feet.
211
diabetes patients usually have what in their extremities
numbest and tingling from bad circulation
212
if you can't find a pulse but patient is awake and alert
use doppler machine
213
anterior chest is also called
the precordium
214
PMI
point of maximal impulse. apical pulse. 5th intercostal midclavicular line
215
where should S2 be louder
at pulmonic and aortic areas
216
where should S1 be louder
at mitral and tricuspid area
217
S3
extra heart sound that occurs just after s2 can be normal in children. also called kentucky
218
S4
extra heart sound occurs just before S1. normal in children. also called Tennessee
219
cardiomegaly
enlarged heart, so pulse may be found at 6th intercostal space
220
trendelenburgs test
evaluates the saphenous vein valves and retrograde filling of the superficial veins. elevate leg and apply tourniquet. help them stand and assess venous filling which should be from bottom up
221
ankle brachial pressure index (ABI)
used to predict severity of PAD - peripheral artery disease . compares BP of ankle and brachial
222
Coronary artery disease risk factors
(CAD) if you are at risk for MI or Cerebral vascular accident
223
PAD
peripheral artery disease
224
CVA
cerebral vascular accident = stroke
225
what causes CAD
plaque build up, blood clot, or coronary spasm
226
risk reduction for CAD
exercise, healthy eating, stop smoking, weight control, lipid management, DM management, HTN management, stress control, genetics
227
someone has a Mi every
42 seconds
228
dyspnea
Shortness of Breath
229
what is angina pectoris caused by
ischemia of myocardium caused by plaque within coronary arteries but can also be caused by other reason
230
PE
pulmonary embolism
231
MSK
musculoskeletal
232
GERD
gastro esophageal reflux disease
233
cardiac arrest
heart stops
234
myocardial infarction
occurs when myocardial ischemia is sustained resulting death of myocardial cells
235
NSTEMI
someone who we don't see changes in EKG but think the are having MI. vessel is semi blocked bu still has some blood flow
236
STEMI
see changes in EKG. means vessel is completely blocked
237
atrial fibrillation
(AFIB) most common irregular heart rhythm
238
signs of atrial fibrillation
palpitations, weakness, fatigue, lightheadedness, dizziness, confusion, SOB, chest pain
239
AFIB RVR
rapid ventricular rate
240
risk factors for PVD
obesity, sedentary life style, smoking, genetics, DM11, HTN
241
intermittent claudication
pain that is relieved with rest
242
rubor
red
243
arterial ulcer characteristics
tips of toes, heel, very painful, deep, circular shape, minimal edema
244
venous ulcer characteristics
medial malleolus or anterior tibial, less painful than arterial, superficial depth, irregular border, granulated tissue, edema moderate to severe
245
atherosclerosis
hardening of artery
246
aneurysm
ballooning of vessel
247
DVT
deep vein thrombosis. clot develops within a vein
248
thrombophlebitis
inflammation of vein that may or may not be accompanied by a clot
249
DVT risk factos
hospital admission, any condition with increased blood clotting, decrease blood flow, pregnancy, over 60, overweight, birth control, sedentary lifestyle
250
varicose veins
incompetent valves in veins, weak vein walls
251
cardiac output
amount of blood pumped by each ventricle in 1 minute. CO=SV X HR
252
SV
stroke volume - amount of blood pumped by each ventricle with each heart beat
253
stoke volume is affected by
pre-load, after-load, and contractibility
254
HR affected by
sympathetic and parasympathetic nervous system, hormones, medications, ect.
255
Normal adult cardiac output
5-6 L/min
256
ejection fraction
measures the amount of blood that is ejected from the heart during systole - provides information about function of the left ventricle during systole
257
lymph system
filters and removes waste
258
CKD
chronic kidney disease
259
beta blockers
blood pressure medication
260
paresthesia
numbness of tingling
261
chronic swelling can cause skin to
appear brown or dusky
262
how do you tell the difference between carotid artery and jugular venous pulse
jugular venous pulse usually has 2 pulsations with a prominent decent, while carotid pulse has 1 pulsation and a prominent ascent
263
assessing pitting edema and grade
apply pressure on shin.
0+ - no pitting edema
1+ - mild (2mm)
2+ - deeper pit (4mm) disappears in 10-15 sec
3+ - deep pit (6mm) last more than a minute
4+ - severe (8mm)- can last more than 2 minutes
264
conditions contributing to murmurs
increased blood velocity, structural valve defects, valve malfunction, abnormal chamber openings
265
diastolic heart murmur always indicates
heart disease
266
valve stenosis
valve opening is narrowed. tissue is stiffer. heard during diastole when valve is opening. forward flow of blood impaired
267
valve regurgitation
incomplete valve back flow of the blood. heard when valve is trying to close.
268
crackles
consolidation in the lungs usually fluid
269
wheezes
narrowing of airways
270
pleural friction rub
pleural surfaces rubbing together
271
pericarditis
inflammation of the pericardial sac. chest pain that is worse with inspiration and lying flat and relieved by sitting up.
272
with pericarditis will sounds still be there when patients hold their breath
yes
273
untreated strep throat can do what to the heart
can cause heart murmur
274
infective endocarditis
infection of endothelial layer of heart. murmur heard during late infection
275
cor pulmonale
right ventricle hypertrophy
276
heart failure
occurs when either ventricle fails to pump. can be systolic or diastolic. can be left or right, but primary cause of left sided heart failure
277
if you can't pump right
back up into systemic
278
if you can't pump left
back up into lungs
279
pulmonary edema
abnormal accumulation of fluid in alveoli and interstitial spaces or lungs, which impair gas exchange
280
causes of pulmonary edema
left sided heart failure, too much iv fluid, low albumin, lymph malignancies
281
What objective findings would you predict to find with pulmonary edema
SOB, 3 word dyspnea, increased work of breathing, tachypnea, cyanosis or pallor, crackles heard upon auscultation, increased tactile fremitus, Bronchophony potentially present, dull percussion
282
What objective findings would you predict to find with left sided failure
Potentially anxious, pale, cyanotic. Dyspnea, tachypnea, left ventricular heave/palpable thrill, tachycardia, displaced apical pulse, S3 heart sound, Systolic murmur, Crackles (pulmonary edema)
283
what techniques would you use to assess left sided heart failure
Inspect for signs of cyanosis, decreased oxygenation, work of breathing
Palpate/ausculate at point of maximal impulse
Auscultate heart and lung sounds
Could perform lung special techniques to assess for fluid build up in lungs
284
what objective finings would you predict to find with right sided heart failure
Fatigue, JVD, dependent peripheral edema, dusky hyperpigmentation of LE skin, S3 heart sounds, systolic murmur, weight gain, enlarged liver, Right ventricle heave, tachycardia
285
what techniques would you use to assess right sided heart failure
Inspect jugular veins
Palpate for edema
Assess Intake and Output
Auscultate heart and lung sounds
286
what objective finings would you predict to find with mitral valve regurgitation
Many people asymptomatic. Weakness, fatigue, Dyspnea on exertion, palpitations, systolic murmur, possible s3 heart sound. Could be acute- signs of pulmonary edema, thready pulse, cool, Clammy extremities
287
what techniques would you use to assess mitral valve regurgitation
Inspect-work of breathing, oxygen saturation, respiratory rate, skin color and temperature
Palpate pulse
Auscultate heart with bell, lung sounds for signs of pulmonary edema
