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NURS112 > Quiz 2 > Flashcards

Quiz 2 Flashcards

1
Q

Cardiovascular health history questions

A 
chest pain
dyspnea
orthopnea
cough
fatigue
cyanosis
pallor
edema
nocturia
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2
Q

inspection of neck vessels

A

jugular veins

  • identify the external jugular vein [usually visible over the sternomastoid muscle] using tangential lighting while the pt. is supine then when the pt. is at 30 degrees
  • identify the internal jugular vein [usually in the sternal notch]
  • estimate the jugular venous pressure by holding a ruler vertically on the sternal angle and align a straight edge to the highest point the external jugular vein is seen
    • the intersection should read at 2 cm or less
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3
Q

palpation of neck vessels

A

carotid arteries

- palpate one at time feeling for contour, amplitude, and equally bilaterally

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4
Q

auscultation of neck vessels

A

have pt. hold their breath while applying the bell over the carotid artery [the angle of the jaw, mid-cervical area, and base of the neck]

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5
Q

heart sounds: s1 characteristics

A

start of systole
caused by the close of the AV [tricuspid and mitral] valves
louder than s2 at the apex [mitral area]
coincides with the carotid artery pulse

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6
Q

heart sounds: s2 characteristics

A

louder at the aortic area

caused by the closure of the semi-lunar [aortic and pulmonic] valves

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7
Q

heart sounds: s3 characteristics

A

known as a ventricular gallop
heard right after s2
an increase in blood volume which causes vibrations due to rapid ventricular filling
best heard over the apex [mitral area] with the pt. in a side-lying position
normal to be auscultated in children but not in adults
most commonly associated with myocardial failure [CHF]

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8
Q

hearts sounds: s4 characteristics

A

known as a atrial gallop
occurs late in diastole so it is heard right before s1
stiffening of ventricles create vibration [in the atria] from resistance when blood attempts to fill in
best heard over the apex or left sternal border while the pt. is in a side-lying position
normal to be auscultated in the elderly

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9
Q

heart sounds: murmurs

A

gentle, blowing, swooshing sound
caused by turbulent blood flow and collision current during diastole and systole
may be caused by increased velocity of blood, structure defect in valves or unusual opening in chambers

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10
Q

grading murmurs

A

1 lowest intensity, difficult to hear even by expert listeners
2 low intensity, but usually audible by all listeners
3 medium intensity, easy to hear even by inexperienced listeners, but without a palpable thrill
4 medium intensity with a palpable thrill
5 loud intensity with a palpable thrill’ audible even with the stethoscope placed on the chest with edge of the diaphragm
6 loudest intensity with a palpable thrill; audible even with the stethoscope raised above the chest

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11
Q

right-sided heart failure symptoms

A 
systemic congestion
fluid back up into the system
jugular [neck vein] distention
enlarged liver
anorexia and nausea
edema, especially in the hands fingers, legs, or sacrum
distended abdomen
nocturia
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12
Q

left-sided heart failure symptoms

A 
decreased cardiac output
fluid back up into the lungs
fatigue
weakness
angina
confusion
hacking cough at night
dyspnea
crackles in lungs
frothy, pink-tinged sputum
tachypnea
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13
Q

arterial insufficiency symptoms

A 
cooler than normal temperature of legs 
skin changes occur on toes or bony prominence; has a painful, punched-out appearance or regular margins
rubor or elevation pallor
thin, brittle skin
extremity skin loss
thicken opaque toenails
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14
Q

venous insufficiency symptoms

A

warmer than normal temperature of legs
skin changes occur around the lower leg near the ankle due to trauma of the edematous skin; painless with irregular margins
brown, flaky pigmentation [stasis dermatitis]
blue cast and dilated veins [variscosities]
continuous and achy leg pain often relieved by elevating legs or by compressionn stockings

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15
Q

peripheral pulses

A

note the grade, rate and rhythm of the following pulses:

  • radial
  • brachial [found in the antecubital fossa, just medial to the biceps tendon
  • femoral [found just below the inguinal ligament [half-way between the pubis and anterior superior iliac spine]
  • popliteal [found behind the knee against the bone, medial to the lateral tendon]
  • posterior tibial [found between the medial malleolus and the Achilles tendon
  • dorsalis pedis [found lateral to the extensor tendon]
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16
Q

inspection of the abdomen

A

with the pt. supine, assess the abdominal contour standing at the pt.’s right side and looking down
- the contour normally ranges from flat to rounded
assess for symmetry
- the abdomen should be symmetrical bilaterally and display no bulges, masses, or asymmetry
inspect the umbilicus
- normally, it is mid-line and inverted with no discoloration, inflammation or hernia
inspect the skin, particularly visible veins, pulsations, which should not be visible, or surgical lesions
- it should be a smooth, even surface with a homogenous color and no rashes or lesions

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17
Q

auscultation of the abdomen

A

listen to bowel sounds starting in the right, lower quadrant [bowel sounds are always present here] and zig-zag clockwise
- typically they are high-pitched, gurgling, cascading sounds and occur intermittently [about 5-30 time/min]
- bowel sounds do not have to be counted but determine whether they are normal, hypo-active or hyper-active
listen for vascular sounds [bruits] using the bell over the aorta, renal arteries, iliac arteries, and femoral arteries

18
Q

percussion of abdomen

A

begin in the right, lower quadrant and zig-zag clockwise
generally, tympany should be heard with scattered areas of dullness indicating you’re over organs or fat
perform a CVA tenderness test

19
Q

CVA tenderness test

A

instruct the pt. about the procedure and to assume a sitting position
place your non-dominant hand against the costovertebral angle [over the 12th rib]
use the ulnar side of your dominant hand to strike your non-dominant hand
no pain or tenderness should be present

20
Q

palpation of abdomen

A

light palpation of 1 cm starting at the right, lower quadrant and zig-zag clockwise
- abdomen should be soft and non-tender
- there should be no guarding, tenderness, masses, or extreme muscular resistance
deep palpation of 5-8 cm using a bi-manual technique starting at the right, lower quadrant and zig-zag clockwise
- identify any masses and note location, size, shape, consistency, tenderness, pulsation and degree of mobility
palpate the bladder using deep palpation beginning at the symphysis pubis and move upward and outward to estimate bladder borders
- normally, an empty bladder will not be palpable
- a distended bladder is palpated as a smooth, round, and some-what firm mass

21
Q

special testing for abdomen: abdominal girth

A

measure abdominal girth in all pt.’s with abdominal distention at the same time each day [ideally, after voiding] while pt. stands by measuring in the same spot, the circumference of the abdomen

22
Q

special testing for abdomen: rebound tenderness

A

rebound tenderness is done by pressing deeply on the abdomen with a perpendicular hand for a moment and then quickly release pressure

  • normally, no pain will be elicited
  • it is abnormal if as the abdominal wall returns to its normal position, the pt. complains of pain at pressure site [direct] or at another site [indirect]
    • may indicated peritoneal irritation
23
Q

special testing for abdomen: shifting dullness

A

shifting dullness is a test for peritoneal fluid [ascites] by percussing the pt.’s abdomen to out-line areas of dullness [indicating fluid] and tympany and then repeating percussion with the pt. rolled to one side
- a shifting in tympany and dullness indicates excess peritoneal fluid

24
Q

grading of vessel pulses

A

3+ bounding pulse
2+ normal pulse
1+ weak pulse
0 absent pulse

25
Q

grading of muscle strength

A

5 normal [100%], full ROM against gravity, full-resistance
4 good [75%], full ROM against gravity, some resistance
3 fair [50%], full ROM with gravity
2 poor [25%], full ROM with gravity eliminated
1 trace [10%, slight contractility, no movement
0 no contractility
against gravity suggest that the pt. is performing active ROM, with gravity eliminated suggests that the pt. is performing passive ROM

26
Q

ROM: temporomandibular joint

A

open mouth
protract lower jaw and retract
move jaw from side to side

27
Q

ROM: cervical spine

A

flexion [chin to chest]
extension [chin to sky]
lateral bending [ear to shoulder]
rotation [turn chin to shoulder]

28
Q

ROM: shoulders

A

forward flexion [arms straight and out and up
hyperextension [arms straight behind back]
abduction [arms lateral and straight up]
adduction [arms swung to opposite side in front of body]
internal rotation [arms behind hips]
external rotation [arms behind head]

29
Q

ROM: elbows

A

flexion [bend]
extension [straighten]
pronation with flexed arm
supination with flexed arm

30
Q

ROM: wrists

A

flexion [bend hand up]
hyperextension [bend hand own]
radial motion
ulnar motion

31
Q

ROM: carpals

A

flexion [bend fingers up]
hyperextension [bend fingers down]
touch thumb to each fingertip and base of little finger
spread fingers apart then touch them together

32
Q

ROM: hip

A

in a supine position:
- flexion [raise leg with knee extended then with knee to chest]
- abduction [swing leg laterally with knee straight]
adduction [swing leg medially with knee straight]
internal rotation [flex knee and rotate leg inward inward toward other leg]
external rotation [place lateral aspect of foot on knee of other leg move flexed knee outward]
hyper-extension while standing [swing straightened leg behind body]

33
Q

ROM: knees

A

flexion [bend knee]

hyper-extension [extend knee]

34
Q

ROM: ankle and foot

A

dorsiflexion [point toes toward ceiling]
plantar flexion [point toes toward floor]
inversion [turn soles of feet in]
eversion [turn soles of feet out]
abducction [rotate ankle, turn foot away from other foot]
adduction [rotate ankle, turn foot towards other foot]
flex and straighten toes

35
Q

ROM: spine

A

flexion [bend forward at waist]
hyper-extension [bend backward at waist]
lateral bending [bend sideways at waist
rotation [twist shoulders to one side then the other]

36
Q

special testing for musculoskeleton: phalen’s test

A

acute flexion of wrist of 90 degrees for 60 seconds

- there should be numbness or burning

37
Q

special testing for musculoskeleton: tinel’s sign

A

direct percussion of the location of the median nerve at wrist
- there should be no numbness or burning

38
Q

special testing on musculoskeleton: scoliosis test

A

inspect standing
ask pt. to bend forward at waist
check alignment of spine and scapula

39
Q

special testing of musculoskeleton: straight leg raising

A

keep pt.’s knee extended and raise leg just short of where pain is produced
dorsiflex the foot
if sciatic pain is produced, it may indicate a herniated disc

40
Q

special testing of musculoskeleton: muscle leg length discrepency

A

test is used to further test for scoliosis
measure from anterior iliac spine to the media malleolus crossing the medial side of the knee
there shouldn’t be more than an inch differences

41
Q

Herberden’s nodes

A

occur on the distal inter-phalangeal joints

42
Q

Bouchard’s nodes

A

occur on the proximal inter-phalangeal nodes

NURS112 (4 decks)

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