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Health Assessment > Unit 2 Lecture > Flashcards

Unit 2 Lecture Flashcards

1
Q

integumentary system

A
  • skin, hair, nails
  • changes may be the first clue to other health problems
  • functioning skin is essential for health/life
  • reflects pt hydration, nutrition, emotional status
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2
Q

skin fun facts

A
  1. ) largest/heaviest organ
  2. ) waterproof
  3. ) insulating shield
  4. ) 16% body weight
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3
Q

epidermis

A
  • outermost layer
  • first line of defense against pathogens/irritants/moister loss
  • thickness remains constant
  • melanocytes
  • cell that perceive pain, light touch, vibration, temp
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4
Q

melanocytes

A
  • 2 types
  • determine skin color
  • in epidermis
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5
Q

dermis

A
  • connective tissue- elastin and collagen
  • contains bld vessels, nerves, sebaceous/sweat glands, lymph vessels, hair follicles
  • thickness varies throughout life and between genders
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6
Q

collagen and elastin

A
  • found in dermis

* provide resiliency, distensibility, elasticity, and turgor of skin

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7
Q

dermal thickness

A
  • thinest at birth
  • thickens until 4th decade and thins again
  • thicker in men b/c more androgens
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8
Q

subcutaneous layer

A
  • fat, loose connective tissue
  • insulation
  • storage of caloric reserves
  • cushioning
  • lose w/ aging
  • provides skin recoil
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9
Q

pigments that determine skin color

A
  • melanin
  • carotene
  • oxyhemoglobin
  • deoxxygemoglobin
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10
Q

melanin

A
  • amt genetically determined
  • Amt increases by exposure to sunlight
  • protects skin agains UV
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11
Q

carotene

A
  • golden yellow

* in SQ fat, palms, soles

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12
Q

hemoglobin

A
  • carries most of O2
  • bright red when carrying O2 (oxyhemoglobin)
  • blue when loses O2 (deoxyhemoglobin)
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13
Q

jaundice

A

•yellowish color
•deposition of bilirubin
•observed in sclera, nails, palms, soles
*hard to see in artificial light

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14
Q

cyanosis

A
  • bluish color
  • lack of O2 (central)
  • lack of blood flow (peripheral)
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15
Q

albinism

A
  • pale, milky skin, flaxen hari, and light irises
  • 1/17,000 Americans
  • lack melanin
  • defenseless against sunlight and more prone to skin cancer
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16
Q

hair

A
  • protects body from debris/invasion

* insulation

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17
Q

vellus

A
  • short, fine, inconspicuous, unpigmented hair

* all over body

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18
Q

terminal

A
  • course, thick, conspicuous, pigmented hair

* scalp, brows, eyelids, axillae, perineum, legs, chest

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19
Q

sebaceous glands

A
  • support each hair follicle
  • secrete sebum for moister/conditioning
  • reduce H2O loss
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20
Q

sweat glands

A

•fxn in thermoregulation by controlling evaporation and resorption

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21
Q

eccrine sweat glands

A
  • widely distributed
  • open directly onto surface
  • secrete sweat in response to environmental and psychological changes
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22
Q

apocrine sweat glands

A
  • found in axillae, perineal areas
  • stimulated by emotional stress
  • responsible for BO
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23
Q

nails

A
  • matrix in epidermal layer at distal fingers/toes
  • nail plated (hardened keratine) grows at varying rates
  • lunula- half moon just above cuticle
  • growth/thickness can be affected by DZ
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24
Q

fxn skin

A
  • barrier
  • thermoregulation
  • synth vit D
  • sensory
  • nonverbal comm.
  • ID
  • wound repair
  • excretion metabolic waste
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25
Q

skin as barrier

A
  • protects against injury (physical, chemical, thermal, UV)
  • prevents penetration of organisms
  • prevents loss of H2O and elecrolytes
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26
Q

skin and perception

A

•touch, pain, temp, pressure

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27
Q

skin and thermoregulation

A
  • sweat glands- cool

* subcutaneous tissue- insulates

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28
Q

skin and expression

A

•huge role as canvas for the artistic/spiritual

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29
Q

pediatric skin

A
  • apocrine immature fxn until puberty
  • eccrine produced in lower amounts
  • more terminal hair in axillae/perineum at puberty
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30
Q

comedones

A
  • blackheads and acne
  • form during puberty when apocrine glands mature and large ants sebum is builds up on hair follicles of face, neck, chest, back
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31
Q

Linea nigra

A

•hormonal changes in preggo cause darkened line from umbilicus to pubic area

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32
Q

older adult skin

A
  • atrophy
  • loss of elastin/collagen
  • sub fat -> decreased resilience, sagging, wrinkling
  • increased visibility of superficial vascular structures
  • increased shearing/bruising
  • rougher- less epi repain
  • slower wound heal
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33
Q

health history subjective data of integument

A

•ID of

  1. ) disease
  2. ) abuse
  3. ) risk for pressure ulcer/cancer
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34
Q

concerning integument symptoms

A
  • rash
  • pruritis- itching
  • non healing
  • moles/lesions
  • ecchymosis
  • dry/too moist
  • hair loss
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35
Q

melanoma

A
  • first degree relatives w/ increase pt risk
  • 10% of pt have relative
  • key is to teach early signs and use of sunscreen
  • results from exposure to UV-B
  • increased risk if dysplastic nevi or > 50 moles
  • found in face, shoulder, upper arms, back (men), legs (women)
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36
Q

integument past history

A
  • skin diseases
  • diabetes/peripheral vascular disease
  • allergies/sensitivities
  • (sun)burns
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37
Q

inspecting skin

A
  • start at head/scalp
  • use good lighting/draping
  • note areas of brittle/broken/absent hair
  • note pigmented areas- freckles/moles/birthmarks
  • look for widespread color change
  • progress down body to feet
  • palpate for moisture, temp, texture, mobility, and turgor
  • inspect skin folds
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38
Q

benign lesions

A

•freckles, moles, birth marks, skin tags, cherry angiomas

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39
Q

turgor

A
  • measure of skin elasticity
  • speed at which skin returns to normal after lifted
  • decreases w/ thinning of dermis and reduced elastin production (aging)
  • affected by hydration status
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40
Q

tenting

A

•skin with decreased turgor remains elevated after being pulled and released
•loss of elasticity due to dehydration/aging
* test at sight w/ less sun exposure

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41
Q

edema

A
  • excess fluid in interstitial spaces
  • skin puffy/tight
  • localized indicates injury
  • systemic- fluid goes to dependent part of body
  • pitting/nonpitting
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42
Q

1+ pitting

A
  • 2 mm depression
  • barely detectable
  • immediate rebound
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43
Q

2+ pitting

A
  • 4 mm deep pit

* few sec rebound

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44
Q

3+ pitting

A
  • 6 mm deep pit

* 10-12 sec rebound

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45
Q

4+ pitting

A
  • 8 mm deep pit
  • very deep
  • > 20 sec rebound
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46
Q

physical exam lesions

A 
•locations/distribution
•pattern/shape/color
•type
•elevation
•exudate
*must describe exactly what is seen
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47
Q

primary lesion

A

•lesion develops on skin that was normal

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48
Q

secondary lesion

A
  • changes in lesion over time

* seen in over treatment, scratching, infection of primary

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49
Q

vascular lesion

A
  • develop b/c of blood supply problem to skin
  • purpura
  • port wine stain
  • telangiectasias
  • venous lake- varicose veins
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50
Q

pt w/ decreased mobility

A
  • susceptible to skin damage/ulceration/microorganisms
  • sustained compression obliterates blood flow
  • distortion of soft tissue
  • moisture promotes maceration of tissue and skin breakdown
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51
Q

pressure ulcers

A
  • caused by sustained compression, friction, shearing forces, moisture
  • easier to prevent than heal
  • use Braden scale- low score= high risk
  • common at sacrum, butt, greater trochanter, knees, heels, elbows, skin folds, back of head, under tubing
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52
Q

Braden Scale

A 
•an assessment tool for predicting the risk of pressure ulcers
•score of less than 18 is risk
•based on the total of scores in
1.) sensory perception
2.) moisture
3.) activity
4.) mobility
5.) nutrition
6.) friction/shear
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53
Q

stages of pressure ulcers (I-IV)

A

I- alteration of intact skin; changes in temp, consistency, sensation, color
II- partial thickness skin loss of eli/dermis
III- full thickness skin loss w/ damage to subcutaneous tissue and maybe muscle; necrosis
IV- full thickness skin loss w/ damage to underlying muscle/bone/etc; necrosis

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54
Q

assessing for vascular blood supply

A
  • direct pressure of finger or on skin surface of nail beds
  • skin should blanch (pale) and promptly return to normal upon release
  • delayed return of color indicates decreased circulation
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55
Q

arterial insufficiency

A
  • vascular lesion
  • poor arterial perfusion
  • pale around b/c blood not getting to
  • punched outlook
  • well defined margins
  • painful
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56
Q

venous stasis ulcer

A
  • vascular lesion
  • red around b/c blood not getting out
  • venous valves don’t work
  • blood pools/leaks, causing breakdown
  • chronic pain
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57
Q

macule

A 
•1° lesion
•non palpable
•change in color of skin
•up to 1.0 cm 
*freckle
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58
Q

patch

A
  • 1° lesion
  • non palpable
  • macule > 1.0 cm
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59
Q

vesicle

A
  • 1° lesion
  • palpable
  • serous fluid filled
  • up to 1.0 cm
  • Ex: chix pox; blister; herpes
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60
Q

bulla

A 
•1° lesion
•palpable
• > 1.0 cm vesicle
•serous fluid
*big vesicle
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61
Q

pustule

A

•1° lesion
•puss filled
*acne

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62
Q

burrow

A
  • 1° lesion
  • fluid filled
  • slightly raised tunnel in epi
  • mites/scabes
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63
Q

papule

A 
•1° lesion
•solid
•distinct borders
•up to 1.0 cm
*mole
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64
Q

nodule/tumor

A

•1° lesion
•solid
• > 1 cm
*wart; cyst

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65
Q

plaque

A
  • 1° lesion
  • solid mass
  • > 1.0 cm
  • often coalescence of papules
  • flat top (plateau)
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66
Q

wheal

A

•1° lesion
•solid mass
*hives/insect bites

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67
Q

crust

A
  • 2° lesion
  • dried residue of skin exudates
  • dried serum, pus, blood
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68
Q

scale

A
  • 2° lesion
  • thin flak of dead
  • psoriasis; dandruff
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69
Q

fissure

A
  • 2° lesion
  • linear crack in skin due to excessive dryness
  • tinea pedis
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70
Q

erosion

A
  • 2° lesion
  • nonscarring loss of superficial epi
  • moist
  • doesn’t bleed
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71
Q

ulcer

A
  • 2° lesion
  • deeper loss of eli/dermis
  • bleed and scar
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72
Q

excoriation

A
  • 2° lesion

* linear or punctate erosions caused by scratching

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73
Q

lichenification

A
  • 2° lesion
  • visible/palpable thickening of epi w/ roughing of skin
  • thick, leathery skin due to rubbing/scratching
  • atopic dermatitis, eczema
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74
Q

scar

A
  • 2° lesion

* extra connective tissue arises from injury/disease

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75
Q

keloid

A 
•2° lesion
•hypertrophic scarring that extends beyond borders of initial injury
•overgrowth of granulation tissue
•firm/rubbery
*Mike's arm
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76
Q

purpura

A
  • vascular lesion
  • deep reddish purple
  • flat
  • > 3 mm
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77
Q

petechiae

A
  • vascular lesion

* small purpura (1-3 mm)

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78
Q

port wine stain

A
  • vascular lesion
  • ruby red mark on skin
  • due to abnormal aggregation of caps.
  • vascular birth mark
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79
Q

telangiectasias

A
  • vascular lesion
  • dilated small vessels
  • spider veins
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80
Q

venous lake

A
  • vascular lesion

* varicose veins

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81
Q

mongolian spots

A
  • common in dark-skinned native am. and hispanic babies
  • flat gray-blue in color
  • caused by pigment that didn’t make it to top layer of skin when formed
  • harmless and fade with age
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82
Q

striae gravidarum

A
  • atrophic, pinkish/purplish scar-like lesions that later become white
  • due to weakening of elastic tissues during pregnancy
  • on breasts, thighs, and butt
  • also associated with overweight, rapid growth during puberty, Cushing’s syndrome, and corticosteroid use
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83
Q

ephelides freckles

A

•flat light brown spots that appear in sun and fad in winter

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84
Q

lentigines freckles

A
  • small tan, brown, or black spots that do not fade in winter
  • bigger than freckles
  • in older people- sun exposure
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85
Q

dermatophyte

A
  • mold-like fungi that thrives in warm, moist ares
  • contagious
  • tx w/ topical agents
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86
Q

tinea capitis/corporis

A
  • ringworm

* capitis- of scalp

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87
Q

tinea pedis

A

•athletes foot

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88
Q

hirsutism

A
  • female has male pattern hair distribution

* found often with polycystic ovarian syndrome

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89
Q

performing skin self examination (SSE)

A 
•ABCDE method
Asymmetry
Border irregularity
Color variation (esp. blue/black)
Diameter 6 mm or greater
Evolving shape/size/color
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90
Q

melanoma prevention

A
  • reduce midday sun exposure- when UV-B rays most intense
  • use at least 15 SPF
  • reapply every 2 hrs
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91
Q

older adult nose/ears

A
  • continue to grow
  • skin sags w/ loss of subcutaneous fat
  • lesions likely
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92
Q

silent thyroiditis

A

•slight enlargement of thyroid in some preggo

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93
Q

fontanel

A
  • a space between the bones of the skull in an infant or fetus, where ossification is not complete and the sutures not fully formed
  • main one is between the frontal and parietal bones
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94
Q

hypothyroidism

A
  • cold intolerance
  • coarse hair
  • thinning brows
  • fatigue
  • anorexia
  • dry skin
  • irregular menstruation
  • weight gain
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95
Q

hyperthyroidism

A
  • heat intolerance
  • thin hair
  • weight loss
  • anxiety
  • increased BP, HR, diaphoresis
  • muscle weakness/fatigue
  • exophthalmia- bulging eyes
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96
Q

facial features not symmetrical

A

•indicates CN7 (facial) nerve damage

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97
Q

preorbital edema

A

•swelling around eyes

98
Q

trachea not midline

A

•indicates respiratory abnormality

99
Q

thyroid cartilage

A

•superior lump of trachea

100
Q

cricoid cartilage

A
  • inferior lump of trachea

* thyroid gland inferior to it

101
Q

jugular venous distention

A
  • blood flow refluxes (flows backward) from R atrium into jugular vein
  • most easily observed in visible upright position w/ head of bed elevated to 30°
102
Q

check for JVD

A
  • have pat. turn head
  • look for pulsation
  • if see pulsation determine if carotid pulse or JVD
103
Q

carotid vs JVD

A
  • palpate radial pulse while observing neck

* if single pulsation that coincides w/ radial pulse -> CAROTID PULSE

104
Q

documentation of head findings

A

•shape of skull and distribution of hair

105
Q

documentation of neck findings

A
  • describe trachea
  • neck symmetry
  • thyroid gland- palpable? nodules?
106
Q

documentation of lymph nodes

A
  • palpable?
  • location of adenopathy
  • tenderness
  • movement
107
Q

hyperopia

A

•farsightedness

108
Q

presbyopia

A

•aging w/ vision loss of near vision

109
Q

myopia

A

•nearsightedness

110
Q

scotoma

A

•areas of lost/depressed vision surrounded by normal vision

111
Q

diplopia

A

•double vision

112
Q

strabismus

A

•muscle weakness

113
Q

cranial nerve III

A

•ocular motor

114
Q

cranial nerves IV and VI

A
  • extracoular movements
  • IV- trochlear
  • VI- abducens
115
Q

extraocular structures

A
  • support and protect eye
  • eyelids
  • palperbral fissure
  • limbus
  • conjunctiva
  • lacrimal apparatus
116
Q

palpebral fissure

A

•almond shaped open space between eyelids

117
Q

limbus

A

•border between cornea and sclera

118
Q

conjunctiva

A

•thin mucous membrane that lines palpebral (inner eyelids) and bulbar (covers sclera)

119
Q

meibomian glands

A
  • sebaceous glands inside tarsal plate at rim of eyelids
  • supply oil meibium, preventing evaporation of eye’s tear film
  • prevents tear spillage
  • makes closed lids airtight
120
Q

lacrimal apparatus

A
  • lacrimal gland/sac/duct
  • protects and lubricates cornea and conjunctiva
  • produces and drains tears
121
Q

extra ocular eye muscles

A
  • oppose each other- ctx vs rlxn

* controlled by cranial nerves 3, 4, and 6

122
Q

cornea reflex

A
  • CN 5, & 7
  • cornea is very sensitive to touch
  • tested w/ cotton ball touch
123
Q

middle layer eye

A 
*vascularized
•iris- light in/out
•lens- focus
•ciliary body- aq. humor/lens shape
•choroids- bld vessels
124
Q

inner layer of eye

A

*nerual
•retina
•optic disk
•macula

125
Q

what opthalmoscope shows

A
  • look thru pupil into retina

* look at choroids, optic disk, and macula for signs of dz

126
Q

subjective data eye examination

A
  • vision changes
  • pain/redness/swelling
  • stabismus, diplopia
  • discharge/watering
  • past hx
  • glaucoma, cataracts, diabetic retnopathy
  • use of glasses
  • self care- regular exams
  • environmental hazards
127
Q

order of eye exam

A

•inspect
•palpate
•percuss
*assessing visual activity, fields, and fxn of CN 2, 3, 4, and 6

128
Q

eye exam key

A
  • wash hands
  • wear gloves if suspect infection
  • clean equip. between eyes
  • examine infected eye last
129
Q

inspection of external eye

A
  • brows
  • lids/lashes
  • moist/glossy eyeballs
  • conjunctiva/sclera color
  • cornea/lens
  • iris/pupil
130
Q

conjunctiva coloring

A
  • pink- normal
  • red- infection
  • pale- anemia
131
Q

cornea/lens inspection

A
  • shine light from side to side

* look for smoothness/clarity

132
Q

iris/pupil inspection

A
  • size/shape

* should be 2-6 mm and round

133
Q

Cranial III damage

A
  • unilateral dilated pupil

* doesn’t react to light/accomodation

134
Q

aging adult eye

A
  • decrease fxn lacrimal glands
  • presbyopia
  • cararacts
  • glaucoma
135
Q

color blindness

A
  • x-linked
  • 8% of males
  • rare in females
  • diagnosed b/t 4-8 y/o
136
Q

Snellen eye chart

A

•test central visual acuity
•top # distance from chart (should be 20 ft)
•bottom # distance normal eye could see specific line on chart, that pt can’t see
*larger denominator -> poor vision

137
Q

confrontation test

A
  • test visual fields
  • place hands 2 ft apart (lat to pt ears)
  • wiggle fingers and move into line of gaze- pt indicate seeing
138
Q

Hirschberg test

A
  • corneal light reflex
  • inspect extraocular fxn
  • pt look at nurse nose
  • shine pen light at pt nose
  • cornea reflection should be =
139
Q

cover test

A
  • inspect extraocular fxn
  • pt look at nurse nose
  • cover one eye
  • note if gaze shifts in opp. eye
  • uncover eye- note if gaze steady
  • if gaze jumps to focus -> muscle weakness
140
Q

cardinal fields of gaze test

A 
•inspect extraocular fxn
•hold finger 14 inches from eye
•start in center
•move finger up and right
•move back midline
•lateral right
•midline
•down right
•midline
•repeat to left
*should move smoothly and symmetrically
141
Q

pupillary light reflex

A

•darken room and gaze at spot behind nurse
•advance light from side to side
*testing CN 3

142
Q

direct light reflex

A

•pupillary light reflex when there is constriction of same side pupil that light is shining on

143
Q

consensual light reflex

A

•pupillary light reflex when there is constriction of other pupil that light is not shining on

144
Q

testing pupil accommodation

A

•reflects CN 3
•far-to-near focus
•pt stare at diet. for 30 sec
•pen light 14 in in front of nose
•pt focus on light as move toward nose
•pupils should constrict and eyes should converge
*pupils should dilate when looking far away- let light in

145
Q

PERRLA

A 
*pupil documentation
Pupils
Equal 
Round
React to
Light &
Accommodation 
•Ex: pupil 4 mm, round and equal bilaterally; react to light/accom. equally
146
Q

3 levels auditory system

A
  1. ) peripheral- ear converts vibration to impulse
  2. ) brain stem- ID/localize sound
  3. ) cortex- interpret/respond
147
Q

conductive hearing loss

A
  • external/middle ear dysfunction
  • sound wave transmission disrupted
  • partial loss only
  • foreign bodies, perforated drum, infection
  • caused by excessive noise exposure in adults
148
Q

inner ear

A
  • provides body w/ proprioception/equilibrium

* dysfunction indicated by staggering gait, or vertigo

149
Q

hearing in > 70 y/o

A
  • men highest incidence of loss
  • greater delays in AP response of brain
  • longer auditory rxn time
150
Q

inspection/palpation of ear

A
  • size/shape
  • skin conditions
  • tenderness
  • external auditory meatus
151
Q

otoscopic examination

A
  • used to inspect ear canal and tempanic membrane
  • 4 mm speculum for adults
  • pull ear back to straighten canal before inserting
  • insert halfway then look into as advance toward tympanic membrane
  • look for redness, fluid, or foreign bodies
152
Q

infant eustachian tube

A
  • horizontal

* pull helix back and up when inserting otoscope

153
Q

> 3 y/o eustachian tube

A
  • sloped

* pull helix down when inserting otoscope

154
Q

voice test

A
  • testing hearing acuity (high frequency loss)
  • push tarsus in (plug) opp. ear
  • whisper 2 syllable word
  • have pt repeat
155
Q

tuning fork tests

A
  • test air and bone conduction

* AC > BC (normal)

156
Q

Rinne Test

A 
•tuning fork test
•place stem of fork on mastoid process (BC)
•pt signal when sound goes away
•place tines of fork next to ear (AC)
•pt signal when sound goes away
*AC should be 2x long as BC
157
Q

Weber Test

A
  • tuning fork test for pt w/ eating better in 1 ear
  • tests BC only
  • fork at midline of skull
  • should hear equally in both ears
158
Q

patency of nares (nostrils)

A
  • are nostrils open
  • sniff on each side
  • test CN 1
159
Q

palpating sinuses

A
  • frontal above eyes
  • maxillary below eyes
  • tenderness or fullness indicates infection
160
Q

inspecting mouth

A
  • wear gloves
  • condition of teeth major indication of health
  • use gauze for tongue
  • use finger for floor
  • use tongue blade for buccal mucosa
  • hard and soft palate
  • uvula
  • tonsils
  • gag reflex
161
Q

inspecting uvula

A
  • should be midline

* pt says “agh”- should rise (CN 10-vagus- in tact)

162
Q

tonsil grading

A
  • absent
  • 1+ barely visible
  • 2+ halfway to uvula
  • 3+ touching uvula
  • 4+ touching each other
163
Q

testing gag reflex

A
  • place tongue blade on post. dorsum of tongue

* if gag, CN 12 (hypo), 9 (gloss), and 10 (vagus) in tact

164
Q

suprasternal notch

A

•top of manubrium

165
Q

sternal angle

A
  • b/t manubrium and sternal body
  • at 2nd rib
  • trachea bifurcates behind into primary bronchi
166
Q

cardiac notch

A
  • left lung

* 5th intercostal space

167
Q

costal angle

A
  • below sternum

* part of abdomen between ribs

168
Q

midsternal line

A

•vertical down sternum

169
Q

midclavicular line

A
  • middle clavicle to end
  • verticle
  • encompasses nipple
170
Q

anterior axillary line

A
  • vertically at most anterior below axillary

* also have mid and post. axillary line

171
Q

scapular line

A

•vertically through center of scapula

172
Q

vertebral line

A

•down spine

173
Q

inferior angle

A
  • bottom, medial corner of scapula

* 7th intercostal space

174
Q

lower lungs

A
  • where to listen for pulmonary edema

* majority in posterior of body

175
Q

inspiration

A
  • muscles ctxn
  • thorax expands
  • pressure in lungs lower -> air in
176
Q

expiration

A
  • muscles relax
  • thorax contracts
  • pressure in lungs greater than atm
177
Q

4 fxn respiraton

A
  1. ) supply O2
  2. ) expel CO2
  3. ) acid/base balance
  4. ) heat exchange
178
Q

adult respiratory system

A
  • muscle strength decline at 50
  • increased dyspnea
  • increased risk pneumonia
  • decreased lung elasticity
179
Q

sudden onset dyspnea indicates

A
  • anaphylaxis
  • pulmonary embolism
  • pneumothorax
  • anxiety
180
Q

wheezes indicates

A
  • airway obstruction
  • tissue inflammation
  • asthma
181
Q

cough indicates

A
  • L side heart failure-blood reflux into lungs
  • upper resp. infection
  • bronchitis/pneumonia
182
Q

assess resp. and thorax

A
  • rate, rhythm, effort
  • use of accessory muscles
  • facial expression
  • LOC
  • shape of chest
183
Q

tactile fremitus

A
  • palpable vibrations transmitted through brochopulmonary tree to chest wall as pt is speaking
  • use ball of your hand
  • not used much b/c x ray would reveal more
184
Q

normal percussion supraclavicular

A
  • resonance

* where apex of lungs is located

185
Q

normal percussion scapular

A
  • flat
  • don’t want to be over scapula
  • want to go b/t scapula and spinal column
186
Q

normal percussion lungs

A

•resonant

*not tympany

187
Q

normal percussion LLL/diaphragm

A

•visceral dullness

188
Q

normal percussion RLL/diaphragm

A

•liver dullness

189
Q

normal breath sounds

A 
•tracheal
•broncho-vesicular- b/t scaulae
•bronchiole- manubrium 
•vesicular- majority of lungs
*inspiration longer than expiration
190
Q

adventitious breath sounds

A
  • abnormal
  • crackles (rales)
  • wheezes
191
Q

crackles (rales)

A
  • air passing through fluid or re-expanding collapsed small airways
  • discontinuous
  • brief
  • intermittent
  • non musical
  • fine vs course
  • not cleared when coughing
192
Q

wheezes and Rhonchi

A 
•turbulent air flow
•continuous
•higher pitched
•musical
*wheezes over tissue; Rhonchi over main bronchi
*Rhonchi are coarse (mucus related)
193
Q

when hear abnormal breath sounds

A
  • location
  • bilateral?
  • during inspiration/expiration/both
  • amnt
  • clear w/ coughing?
194
Q

respiratory auscultation key

A
  • hold diaphragm firmly on chest wall
  • move from side to side to compare for symm
  • 14 locations post.
  • 12 locations ant
195
Q

abdomen facts

A
  • every structure except respiratory found there
  • xyphoid process to pubic bone
  • 4 flat muscle joined by Linea alba
196
Q

GI fxn

A
  • ingestion
  • digestion
  • absorption of nutrients
  • elimination of solid waste
197
Q

peritoneum

A
  • serous membrane beneath muscle layer of abdomen

* cover/holds organs in place

198
Q

parietal layer

A

•lines walls of abdomen

199
Q

visceral layer

A

•coats outer surface of organs

200
Q

diastasis recti

A
  • separation of rectus abdomens muscles at linea alba

* looks like a hernia, but it’s not

201
Q

organs in RUQ (5)

A
  • liver
  • gallbladder
  • duodenum
  • pancreas
  • R kidney/adrenal
202
Q

organs in LUQ (4)

A
  • spleen
  • stomach
  • pancreas
  • L kidney/adrenal
203
Q

organs in RLQ (3)

A

•cecum
•appendix
•R ovary
*where you begin examination

204
Q

organs in LLQ (2)

A
  • L ovary

* sigmoid colon

205
Q

organ in hypogastric region

A

•bladder

206
Q

spleen

A
  • stores RBCs/platelets
  • produces new RBCs
  • produces WBCs
  • not normally palpable
207
Q

mesentery

A
  • a fold of the peritoneum that attaches the stomach, small intestine, pancreas, spleen, and other organs to the posterior wall of the abdomen
  • supplies blood vessels and nerves to intestinal tract
208
Q

costovertebral angle tenderness

A

•indicates possible kidney problems

209
Q

pediatric abdomen

A
  • less muscle -> easier palpation of organs

* protuberant abdomen until 7 y/o b/c of spine curvature

210
Q

aging adult abdomen

A
  • slower gastric motility
  • smaller liver/decreased fxn
  • decreased activity -> constipation
  • increased risk for gallstones
211
Q

abdomen during preggo

A
  • muscles rlx
  • organs displaced
  • diastatsis recti
  • compression of intestines -> constipation
  • increased venous pressure -> hemorrhoids
212
Q

visceral abdominal pain

A
  • difficult to localize
  • gnawing, burning, cramping, aching
  • may be associated with diaphoresis, pallor, nausea, vomiting, etc
213
Q

parietal abdominal pain

A
  • results from inflammation of peritoneum
  • severe and localized
  • Sx: ache, sharp, more w/ movement
214
Q

referred abdominal pain

A
  • in more distant sites innervated at same spinal level of affected structure
  • may be where organ was during fetal development
215
Q

chronic upper abdominal pain

A
  • dyspepsia
  • discomfort
  • pyrosis
  • atypical resp. symptoms
216
Q

RLQ acute abdominal pain

A
  • sharp/continuous
  • cramping
  • rebound tenderness
  • double over
217
Q

LLQ acute abdominal pain

A
  • fever
  • loss of appetite
  • absent bowel sounds
  • firm
  • guarding
  • rebound tendernes
218
Q

Urinary tract pain

A
  • suprapubic
  • kidney/flank
  • ureteral colic (spasmodic)
219
Q

preparing pt for abdominal exam

A
  • bladder empty
  • supine w/ knees bent
  • exposed abdomen from xiphoid to pubis
  • groin visible, genitals draped
220
Q

examining abdomen order

A
  • inspect, auscultate, percuss, palpate

* ALWAYS begin in RLQ at ileo-cecal valve and move clockwise

221
Q

abdominal profiles (4)

A
  1. ) flat
  2. ) rounded
  3. ) scaphoid- inward
  4. ) protuberant- outward
222
Q

bowel sounds

A
  • use diaphragm softly
  • normal if peristalsis generates noise
  • listen in each quad for 15-20 sec
  • MUST listen for 5 min in all quads to determine absent
223
Q

hyperactive bowel sounds

A
  • > 30/min
  • gastroenteritis/diarrhea
  • hunger
  • behind obstruction
224
Q

hypoactive bowel sounds

A
  • < 5/min
  • preggo
  • peritonitis
  • constipation
  • post surgery
225
Q

normal bowel sounds

A
  • 5-30 sounds/min

* high pitched clicks an gurgles

226
Q

high pitched bowel sounds

A
  • cramping

* intestinal obstruction

227
Q

bruits

A
  • heard as blowing or swishing sounds that reflect turbulent blood flow (use bell)
  • determined when auscultating bowel sounds and carotid arteries
  • more common in atherosclerosis patients
228
Q

thrill

A

•palpated vibration over artery w/ turbulent blood flow

229
Q

tympany

A
  • gas/air
  • LUQ
  • high pitched
  • stomach, sm. intestine, lg. intestine
230
Q

dullness

A 
•solid masses (dense)
•distended bladder
•liver (RUQ)
•spleen
•kidney
*if in area that is normally hollow -> abnormality
231
Q

reasons for dullness in area that should have tympany percussion sound

A
  • masses
  • ascites
  • GI obstruction
  • preggo
232
Q

costovertebral angle (CVA) percussion

A
  • do if pt complains of pain/suspect kidney dz
  • place hand over 12th rib
  • thump ulnar area of fist
  • no pain rules out kidney infection/disease
233
Q

light abdominal palpation

A

•1-2 cm deep w/ fingers
•temp, texture, lesions, tender
•same pattern as auscultation
*be sure to observe facial expressions

234
Q

deep abdominal palpation

A

•5-8 cm w/ hands
•masses, organs, thrill, fluid wave
•same pattern as auscultation
*be sure to observe facial expressions

235
Q

splenomegaly

A
  • enlarged spleen
  • tip is palpable
  • indicates mono, HIV, cancer, infection, RBC abnormality
236
Q

rebound tenderness

A

•pain induced or worsened by withdrawal of palpation
•suggests peritonitis
*assess for tenderness last

237
Q

McBurney’s point

A
  • ⅓ of distance from anterior superior iliac spine (ASIS) to umbilicus
  • location of pain w/ appendicitis
238
Q

abdominal distension

A
  • ascites
  • obesity
  • tumor
  • tumor
  • ovarian cyst
  • gas
  • feces
239
Q

fecal impaction

A
  • seen w/ constipation and excessive use of laxatives
  • muscles forget how to move stool on their own
  • immobile/dehydrated pts at risk
240
Q

bladder

A
  • normally cannot be palpated unless distended

* dull upon percussion

Health Assessment (8 decks)

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