Week Twelve Flashcards
1
Q
Self Concept
A
Ones mental image of oneself
2
Q
Self esteem
A
Ones judgement of one’s own worth; how one’s standards and performance compare to others and to one’s ideal self
3
Q
Personal (self) identity
A
The conscious sense of individuality and uniqueness that is continuously evolving throughout life. Ex. Name, sex, age, race, occupation, talent, roles
4
Q
Body image
A
How a person perceives the size, appearance, and functioning of the body and its parts
5
Q
Role performance
A
How a person in a particular role acts in comparison to the behaviors expected of that role
6
Q
What are the four components of self-concept?
A
Personal identity, body image, role performance, and self-esteem
7
Q
What would a person with strong sense of personal identity exhibit?
A
A person with a strong sense of personal identity would exhibit the integration of all parts of their lives to define themselves such as body image, role performance, and self esteem.
8
Q
What would a person with a healthy body image exhibit?
A
A concern for both health and appearance.
9
Q
What is role mastery?
A
Persons behaviors meet social expectations
10
Q
What is global self esteem?
A
How one likes oneself as a whole
11
Q
What is specific self esteem?
A
His much one approves of a certain part or aspect of oneself
12
Q
What are the key factors that can influence self concept?
A
Stage of development, family and culture, stressors, resources, past history of successes and failure, illness
13
Q
What are the behaviors associated with low self esteem?
A
Avoids eye contact, stooped posture, unkempt appearance, overly critical of self, overly critical of others, hesitant soft speech, unable to accept positive remarks about oneself, apologizes frequently, feels helpless/hopeless/powerless, lack of goals, many negatives
14
Q
What are the behaviors associated with high self esteem?
A
Positive thinking, able to identify strengths, able to set attainable goals, able to provide positive reinforcement and feed back, able to take pride or acknowledge when goals are met, maintaining a sense of humor, able to acknowledge skills, positive relationships, emotional strength, spiritual strength
15
Q
How does an RN go about assessing self concept?
A
Creating a therapeutic environment by establishing rapport, be aware of self attitudes and judgments, gather information on personal identity, body image, role performance, and self-esteem
16
Q
Define disturbed body image
A
Confusion in mental picture of one’s physical self
17
Q
Define risk for situational low self esteem.
A
At risk for developing negative perception of self worth in response to a current situation (specify situation)
18
Q
Define situational low self esteem
A
Development of a negative perception of self worth in response to a current situation (specify situation)
19
Q
Defining characteristics for situational low self esteem
A
Evaluation of self as unable to deal with events, evaluation of self as unable to deal with situations, expressions of helplessness, expressions of uselessness, indecisive behavior, non assertive behavior, self negating verbalizations, verbally reports current situational challenge to self worth
20
Q
R/t for situational low self esteem
A
Behavior inconsistent with values, developmental changes, disturbed body image, failures, functional impairment, lack of recognition, loss, rejection, social role changes
21
Q
Risk factors for risk for situational low self esteem
A
Behaviors inconsistent with values, decrease in control over environment, developmental changes, disturbed body image, failures, functional impairment, history of abandonment, history of abuse, history of learned helplessness, history of neglect, lack of recognition, loss, physical illness, rejections, social role changes, unrealistic self expectations
22
Q
Tnis situational low self esteem
A
Assess for s/s of depression and potential suicide/violent behavior and if present notify appropriate resources and act stat, assess for underlying stressors, assess for unhealthy coping mechanisms, assist pt in indigo citation of problems or contributing factors (make change and offer options), identify strengths, resources available, and previous positive effective coping, accept patient where he or she is, teach positive coping, support and encourage problem solving strategies, encourage self evaluation, provide psycho-education to family, provide validation for pt, acknowledge social stigma, work to address/present a positive outlook, identification of self strengths, and set realistic goals
23
Q
TNIs for risk for situational low self esteem
A
identify environmental/developmental factors that increase the risk for low self esteem, especially in children and adolescences, utilize resources as available and appropriate, assess previous experience with health care and coping, assess low and or negative affect, encourage to maintain highest level of functioning, utilize respect and therapeutic relationship to set realistic goals, and have the client involved in planning care
24
Q
Defining characteristics of disturbed body image
A
behaviors of acknowledgement of one’s body, behaviors of avoidance of one’s body, behavior’s of monitoring one’s body, non-verbal response to actual change in body appearance, structure, function, non-verbal response to perceived change in body, verbalization of feelings that reflect an altered view of one’s body, verbalizations of perceptions that reflect an altered view of one’s body appearance
25
r/t for disturbed body image
biophysical, cognitive, cultural, development changes, illness, illness treatment, injury, perceptual, psychosocial, spiritual, surgery, trauma
26
TNIs for disturbed body image
employ psychosocial questions in assessment to identify clients at risk for disturbed body image, if identified as at risk for disturbed body image utilize a standardized tool to further assess and gather data, utilize resources as appropriate (provide a list of recources to client/family), allow opportunity for client/family to voice concerns, fears, feelings, offer support through positive unconditional regard, and non-judgemental acceptance, acknowledge negative feelings expressed, encourage the client to discuss interpersonal and social conflicts that may arise, explore opportunities to assist the client to develop a realistic perception of his/her body image, encourage client to write a narrative description of their changes, encourage client to involvement in planning care and treatment, take cues from the client regarding their readiness to look at body/wound, and utilize their questions/comments as a means to provide teaching, encourage the client to engage in health promotion behaviors as able and appropriate
27
Aphasia
the partial or total loss of ability to express or understand speech or written words
28
What are the five senses?
visual, auditory, olfactory, tactile, gustatory
29
Signs of Sensory Deprivations
excessive yawning, drowsiness, sleeping, decreased attention span, difficulty concentrating, decreased problem solving, impaired memory, periodic disorientation/general confusion, preoccupation with somatic c/o, hallucinations/delusions, crying, annoyance with small matters, depression, apathy, emotional lability
30
Sensory Deprivation Definition
Low or lack of meaningful stimuli
31
Sensory Overload Definition
Inability to process or manage the amount of intensity of sensory stimuli
32
Signs of Sensory Overload
c/o fatigue, sleeplessness, irritability, anxiety, restlessness, periodic or general disorientation, decrease problem-solving, task performance, increase in muscle tension, scattered attention and racing thoughts
33
Contributing Factors for Sensory Deprivation
sensory input is interrupted (blindness, deafness, paralysis), lack of environmental stimulation, lack of social input, lack of light and lack of visual stimulation
34
Who is at risk for developing sensory deprivation?
unable to process stimuli, prolonged bedrest/mobility restrictions, private room/isolation precautions/home bound, sensory alterations (eyes bandaged), limited social contacts (few visitors), different culture
35
What nursing actions can be taken for those at risk or those with sensory deprivation?
encourage use of sensory aid (glasses, hearing aid), maintain meaningful interactions with client, call the client by name and touch client, provide meaningful environmental stimuli, increase tactile stimulation (textured objects, back rub, foot care, hair wash), encourage social interaction, encourage mental stimulation and use self-stimulating techniques (signing etc.), encourage environmental changes
36
Contributing factors Sensory Overload
increased quantity or quality of internal stimuli (N, pain, anxiety, dyspnea), increased quantity or quality of external stimuli (noise, light, procedures), inability to distinguish stimuli selectively
37
Clients at risk for developing Sensory Overload
Busy/noisy environment (ICU, room near nurse's station, being closely monitored), machinery (o2, telemetry, IV pumps), acutely ill, presence of pain or discomfort, CNS disturbances or decrease in cognitive ability, roommate
38
Nursing actions for those at risk or experiencing sensory overload
quiet, calm subdued environment, control pain, provide orienting cues, plan care to allow uninterrupted periods of rest and sleep (private room if available), establish a routine of care, communicate in a calm, unhurried manner, provide information and client teaching at appropriate level, reduce noxious odors, ask client to ask questions and ventilate feelings, teach client stress-reducing techniques
39
What are the factors affecting sensory function?
developmental stage, culture, stress, medication and illness, lifestyle & personality
40
Nursing Assessment Nursing History Component for Sensory
can interview client as well as family or significant others, focus is on sensory perceptions, functioning, any deficits and on any potential problems
41
Nursing Assessment Mental Status Component for Sensory
Level of consciousness, orientation, attention span, and memory, mini-mental status exam
42
Nursing Assessment Physical Exam Component for Sensory
to determine whether the senses are impaired, visual acuity and visual fields, hearing acuity, olfactory sense, gustatory sense, tactile sense
43
Nursing Assessment Environment Component for Sensory
Is there appropriate and meaningful stimuli in the environment? does the environment pose any safety risks?
44
Nursing Assessment Social Support Component for Sensory
does the client live alone? who visits and when? any signs indicating social deprivation? who provides social contact with this person? important for social stimulation, assistance, support, opportunity to discuss feelings and fears
45
Behaviors of Visually Impaired
poor coordination, squinting, under or over-reaching for objects, persistent repositioning of objects, impaired night vision, accidental falls
46
What are some sensory aids to visually impaired?
sunglasses, contact lenses, eyeglasses, magnifying glass, seeing-eye dog, well lighted areas, large print, braille
47
Nursing Implications for Care of Contact Lenses
facilitate clients who normally care for their clients themselves. contact solution is to be kept sterile.
48
Nursing Actions for Visually Impaired
identify yourself, stay within the client's field of vision, avoid loud voice tones, explain what you will be doing before you touch a client, explain environmental sounds, let client know when you enter and when you leave, do not rearrange furniture or belongings, set up tray for meals and offer assistance, when ambulating give client elbow, never leave client alone in unfamiliar place, allow independence, provide suitable recreation
49
Behaviors of Hearing Impaired
blank look, decreased attention span, lack of reaction to loud noises, increased volume of speech, position of head toward sound, smiling & nodding when someone speaks, lip reading, writing, relying on non-verbals, complaint of ringing in ears
50
Sensory Aids for Hearing Impaired
hearing aid, amplifier (phone), telecommunication device for the deaf, sign language, flashing alarm clocks and smoke detectors, lip reading, hearing guide dog
51
Nursing Actions for Hearing Impaired Clients
decrease background noises when speaking, face clients and make sure light shines on your face and that client can see lips, talk at moderate rate in normal tone of voice, do not shout, position in good ear if applicable, refrain from small talk, use longer phrases to facilitate understanding, choose words wisely, use writing and gestures, be sure hearing aids are in and on and glasses on if client has these, never do anything unexpected from behind, never leave client in complete darkness, be sure you have client's attention before speaking
52
Nursing Implications regarding Care of a Hearing Aid
hearing aids require regular cleaning of the ear-mold, regular replacement of batter, can be switch on and off, volume can be adjusted, ear-molds typically require adjustment ever 2-3 years
53
Define Acute Confusion
Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time
54
Defining Characteristics for Acute Confusion
fluctuation in cognition, fluctuation in level of consciousness, level of consciousness, psychomotor activity, hallucinations, increased agitation, increased restlessness, lack of motivation to follow through with goal-directed behavior or purposeful behavior, lack of motivation to initiate goal-directed behavior or purposeful behavior, misperceptions
55
Define Chronic Confusion
Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior
56
Defining Characteristics of Chronic Confusion
altered interpretation, altered personality, altered response to stimuli, clinical evidence of organic impairment, impaired long-term memory, impaired short-term memory, impaired socialization, long-standing cognitive impairment, no change in level of consciousness, progressive cognitive impairment
57
Reality Orientation
A communication modality used to make a client aware of reality. The purpose is to restore a sense of reality, improve level of awareness, promote socialization, evaluate the client's independent functioning, and/or minimize confusion.
58
Guides for Reality Orientation
time, date, and place during conversation, reference to clocks, calendars and other reality props, do not reinforce or support misconceptions, call the client by name, introduce oneself, redirect if client rambles, encourage independence and provide client with choice, make sure client has necessary sensory or mobility aids, reward even small changes in behavior that indicate progress, repeat info as necessary, give directions and explanations in short sentences with concrete times, maintain consistency in routine and care providers as able, provide visual cues (family photos and possessions in room, written schedule name outside room)
59
Wandering Strategies
doors/windows locked, door alarms, ID bracelets, provide adequate exercise, do not restrain , do not argue c person who wants to leave and instead go with them, let the person wander in enclosed areas, assess any underlying cause (pain, toileting)
60
Agitation Strategies
calm, quiet approach, ensure congruency b/w caregiver verbal and non-verbal behavior, determine cause of behavior and remove cause, individualized music therapy, consistency of care givers, provide for client's and other's safety
61
Define Hallucinations
Seeing, hearing, or otherwise experiencing something that is not present in objective reality
62
Hallucinations Strategies
do not argue c person, identify yourself & purpose for being there, reassure, acknowledge that the person is experiencing something you are not experiencing, do not challenge the hallucination as unreal, do not leave client alone while a hallucination is being experienced or immediately afterward, avoid sedatives or hypnotics
63
Define Sundowning
A state of disorientation and agitation that occurs at night in institutionalized people who are oriented during the day. It is a temporary state of confusion that cycles with the sun.
64
Sundowning Strategies
calm environment late in day, treatments/activities should be done early in the day, do not restrain, encourage exercise and activity early in the day, promote urinary and bowel elimination, do not try to reason with the person, do not ask the person to tell you what is bothering him or her, provide adequate lighting, assess underlying physiologic causes (delirium)
65
Verbal/Physical Abuse Strategies
avoid confrontation, allow to dissipate energy by performing repetitive tasks, decrease by degrees anxiety and aggressive behavior, calmly state that violence will not be tolerated, set limits, define limits, speak slow, clear, behave politely and list uncritically, approach non-threatening manner, maintain same physical level as client, allow plenty of space between yourself and client, reinforce positive behavior, provide for others' safety, alert security, police (show of force)
66
What concepts are included in sexuality?
feelings, sexual orientations, gender roles, self image, touch, values, pleasure, body image, expectations, relationships and intimacy, reproduction and reproductive decisions
67
Infancy/ Early Childhood Sexuality
treatment of child, gender identity within first 3 years, preschool age children are interested in their own and other's body parts, learn correct names for body parts
68
School Age Children Sexuality
strong identification with same sex parent, desires privacy, may have questions/concerns about sexuality and reproduction, need to know what to expect as they approach puberty
69
Puberty/Adolescence Sexuality
need accurate information about body changes, menstruation begins, strong peer influences/pressure, needs accurate factual information about sex, pregnancy, intimacy, relationships
70
Young Adult Sexuality
explore and define emotions, intimacy, communication, sexuality in relationships, learn techniques that are sexually satisfying to self and partner, continue to require information
71
Middle Adult Sexuality
changing physical appearance may lead to concerns about sexual attractiveness, male and female hormonal changes
72
Older Adult Sexuality
physical changes, interest in sexual activity continues, concerns about privacy, depending on living circumstances
73
What information should be collected during a nursing history exam when assessing the client's sexual health status?
are you sexually active? are you unhappy with anything concerning your sexual functioning? are you experiencing any sexual difficulties or pain? has your sexual activity negatively impacted you or your partner? do you have concerns about STDs, pregnancy, HIV or infertility? Are you in need of birth control? Have you noticed any discharge, lumps, or changes in size or shape of your genital organ? what medications do you take? have medication changed how you feel sexually? do you have any chronic medical illnesses or pain? when was your last physical exam?
74
Define Sexuality Pattern, Ineffective
Expressions of concern regarding own sexuality
75
Defining characteristics of Sexuality Pattern, Ineffective
reported difficulties, limitations, or changes in sexual behavior or activities, conflicts involving values
76
R/t for Sexuality Pattern, Ineffective
absent role model, conflicts with sexual orientation/preferences, altered body function, medications, lack of privacy, impaired intimate relationships
77
Permission Giving "P" PLISSIT
client needs permission or validation for their sexual thoughts and feeling, giving permission lets the client know that thoughts, feelings, behaviors, and fantasies among consenting adults is allowed
78
Limited Information "LI" PLISSIT
client needs accurate and concise information, explain what is considered normal
79
Specific Suggestions "SS" PLISSIT
nurse needs specialized knowledge and skill at this intervention level, may offer alternative methods of sexual expression/methods to promote optimal function
80
Intensive Therapy "IT" PLISSIT
provided by an expert when the first three levels of counseling and ineffective, may involve issues of sexual motivation, marriage, or self-concept
81
PERRLA
Pupils are Equal, Round, React to Light and Accomodate
82
What is the normal shape of a pupil?
round
83
Consensual Response
When a light is shone on one pupil and the other pupil becomes smaller
84
Direct Response
When a light is shone on a pupil, that pupil becomes smaller
85
Skeletal muscles contact and pupils...?
constrict
86
Pupils should do what when looking at a distant object?
dilate
87
Pupils should do what when looking at a close object?
constrict
88
Stimulation of the sympathetic nervous system causes what pupil response?
dilation
89
Stimulation of the parasympathetic nervous system causes what pupil response?
constriction
90
What is a snellen chart utilized for?
assessing distance vision
91
How far should a client be from a snellen chart when tested?
20 ft
92
What does the nurse note during a snellen examination?
the smallest line in which the client is able to read HALF OR MORE of the letters
93
The numerator of the snellen chart represents what?
always 20. represents the distance the client stands from the chat
94
The denominator of the snellen chart represents what?
the distance from which the normal eye can read the chart
95
Normal Vision
20/20
96
What does a larger number on a snellen test denominator mean?
poorer visual acuity
97
What is the age range for normal 20/20 vision?
age 6 and up 20/20 vision is considered normal
98
What is 20/40 vision?
A client who can see at 20 feet from the char what a normal sighted person can see at 40 feet
99
Is 20/40 vision LESS than normal or MORE than normal?
LESS.
100
What technique is used to straighten the ear canal of an adult?
pull the pinna up and back
101
What technique is used to straighten the ear canal of a child?
pull the auricle down and back
102
What is cerumen?
"ear wax"
103
How to auscultate breath sounds
ask the client to breath deeply through the mouth. auscultate with the diaphragm during inspiration and expiration at each site. compare bilateral sides
104
Vesicular
like a blister or sac. alveolus. alveoli found over periphery and most of the lung tissue
105
Bronchial
tubular breath sounds are heard over the trachea. Trachea is a tube.
106
Vesicular Breath sound
Inspiration Longer, Low Pitch, Soft & Gentle
107
Bronchial Breath Sounds
Expiration Longer, High Pitch, Loud & Harsh
108
Visual Acuity
the degree of detail the eye can discern in an image
109
Visual Fields
The area an individual can see when looking straight ahead
110
Myopia
nearsightedness.
111
Hyperopia
farsightedness
112
Cataracts
Opacity (clouding) of the lens or its capsule
113
When do clients need to be referred to an ophthalmologist after an eye test?
If their denominator number is 40 or more with or without corrective lenses
114
If a mother contracted rubella during the first trimester of her pregnancy, what problem might you see with the infant's eyes
cataracts
115
Glaucoma
a disturbance in the circulation of aqueous fluid which causes an increase in intraocular pressure. most frequent cause of blindness in people over age 40
116
What to inspect for external eye structure assessment
eyebrows (hair distribution, skin quality and movement), eyelashes (evenness, direction of curl), eyelids for surface characteristics, position in relation to the cornea, ability to blink, frequency of blinking, bulbar conjunctiva for color, texture and the presence of lesions, cornea for clarity and texture, pupil's direct and consensual reaction to light, assess each pupil's response to accommodation
117
Normal Findings External Eye Structure
hair evenly distributed, skin intact, eyebrows symmetrically aligned, equal movement, equal distributed eyelashes and curled slightly outward, skin intact on eyelids, no discharge, no discoloration, lids close symmetrically, approximately 15-20 involuntary blinks per minute, bilateral blinking, when lids open no visible scelera above corneas, and upper and lower borders of the cornea are slightly covered, transparent bulbar conjunctiva, capillaries sometimes evident, sclera appears white (darker or yellowish and with small brown macules in dark skinned clients), transparent shiny and smooth cornea, details of iris are visible, in older people a thin grayish white ring around the margin called arcus senilis may be evident, black pupils, equal in size, normally 3-7mm in diameter, round, smooth border, iris flat and round, illuminated pupil constricts, nonilluminated pupil constricts (consensual response), response is brisk, pupils constrict when looking at near object, pupils dilate when looking at far object, pupils converge when near object is moved toward nose, use PERRLA to record normal assessment of the pupils
118
Abnormal Findings External Eye Structure
loss of eyebrow hair, scaling and flakiness of skin, unequal alignment and movement of eyebrows, eyelashes turned inward, redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions, lids close asymmetrically, incompletely or painfully, rapid monocular, absent or infrequent blinking, ptosis, ectropion, or entropion, rim of sclera visible between lid and iris, jaundiced sclera, excessively pale sclera, reddened sclera, lesions or nodules, opaque cornea, surface of cornea not smooth, arcus senilis in clients under age 40, cloudiness, mydriasis, miosis, anisocoria, bulging of iris toward cornea, neither pupil constricts, unequal response, responses sluggish, absent responses, one of both pupils fail to constrict, dilate, or converge
119
Normal Findings Visual Fields
when looking straight ahead, client can see objects in periphery temporarily, peripheral objects can be seen at right angles to the central point of vision the upward field of vision is normally 50 degrees because the orbital ridge is in the way the downward field of vision is normally 70 degrees because the cheekbone is in the way the nasal field of vision is normally 50 degrees away from the central point of vision because the nose is in the way
120
Abnormal Findings Visual Fields
Visual field smaller than normal (possible glaucoma), one-half vision in one or both eyes (possible nerve damage)
121
Extraocular Muscle Test Normal Findings
both eye coordinated, move in unison, with parallell alignment, light falls symmetrically on both pupils, uncovered eye does not move
122
Extraocular Muscle Test Abnormal Findings
eye movements not coordinated or parallel, one or both eyes fail to follow a penlight in specific directions other than at end point may indicate neurologic impairment, light falls off center in one eye, if misalignment is present, when dominant eye is covered, the uncovered eye will move to focus on the object
123
Strabismus
cross-eyed
124
Nystagmus
Rapid involuntary rhythmic eye movement
125
Normal Visual Acuity Findings
Able to read newsprint, 20/20 vision on snellen-type chart
126
Abnormal Visual Acuity Findings
Difficulty reading newsprint unless due to the aging process, denominator of 40 or more on snellen type chart with corrective lenses, functional vision only (ex. light perception, hand movements, counting fingers at 1 foot away)
127
When is Snellen Chart used?
to test for visual acuity
128
Who is the Rosenbaum eye chart used for?
non-ambulatory cooperative patients
129
Who is the E chart used for?
children or patients that do not know the alphabet or non-verbal patients
130
Who is the picture eye chart used for?
pediatric patients that can not read
131
What is the distance of one floor tile?
1 foot so visual acuity needs 20 tiles away from chart
132
How do you know when a client has light perception (LP)?
The penlight is shone into one eye and the light is turned off and on and client knows when the light is on or off. Documented as LP
133
Otoscope
instrument for examining the interior of the ear, especially the eardrum consisting essentially of a magnifying lens and a light
134
Tympanic membrane
eardrum
135
Cerumen
ear wax
136
Normal Findings Auricles
color same as facial sin, symmetrical, auricle aligned with outer canthus of eye, about 10 degrees from vertical, mobile, firm, not tender, pinna recoils after it is folded
137
Abnormal Findings Auricles
bluish color of earlobes, pallor, excessive redness, asymmetry, low-set ears, lesions, flaky, scaly skin, tenderness when moved or pressed
138
External Ear Canal and Tympanic Membrane Normal Findings
distal third contains hair follicles and glands, dry cerumen, grayish-tan color, sticky, wet cerumen in various shades of brown, pearly gray color that is semitransparent
139
External Ear Canal and Tympanic Membrane Abnormal Findings
Redness and discharge, scaling, excessive cerumen obstructing canal, pink/red/yellow/amber/white/blue/dull tympanic membrane
140
Gross Hearing Acuity Test Normal Findings
normal voice tones audible, able to hear ticking in both ears (watch test), sound is heard in both ears or is localized at the center of the head (tuning fork test), air conducted hearing is greater than bone conducted hearing (tuning fork test)
141
Gross Hearing Acuity Test Abnormal Findings
Normal voice tones not audible, requests nurse to repeat words or statements, leans toward to speaker, turns the head, cups the ears, or speaking in a loud tone of voice, unable to hear ticking in one or both ears, sound is heard better in impaired ear, indicating a bone-conductive hearing loss or sound is heard better in ear without a problem indicating a sensorineural disturbance (weber positive, fork test), bone conduction time is equal to or longer than the air conduction time (fork test)
142
normocephalic
having a normal sized and shaped head
143
Nose Normal Findings
symmetric and straight, no discharge or flaring, uniform color, not tender, no lesions, air moves freely as the client breathes through the nares, mucosa pink, clear watery discharge, no lesions, nasal septum intact and in midline
144
Abnormal Nose Findings
asymmetric, discharge from nares, localized areas of redness or presence of skin lesions, tenderness on palpation, presence of lesions, air movement is restricted in one or both nares, mucosa red, edematous, abnormal discharge, presence of lesions, septum deviated to the right or to the left, tenderness in one or more sinuses
145
adventitious breath sounds
abnormal breath sounds
146
Normal Findings posterior thorax
anteroposterior to transverse diameter in ratio of 1:2, thorax symmetric, spine vertically aligned, spinal column is straight, right and left shoulders and hips are at same heigh, skin intact, uniform temperature, chest wall intact, no tenderness, no masses, full symmetric thorax expansion, bilateral symmetry of vocal fremitus (heard most clearly at the apex of the lungs), low pitched voices of males are more readily palpated than higher pitched voices of females, percussion notes resonate, except over scapula, lowest point of resonance is at the diaphragm, percussion on rib normally elicits dullness, vesicular and bronchovesicular breath sounds
147
Normal Findings Anterior Thorax
Quiet, rhythmic and effortless respirations, costal angle is less than 90 degrees and the ribs insert into the spine at approximately a 45 degree angle,full symmetric excursion, same as posterior vocal fremitus, fremitus is normally decreased over heart and breast tissue, percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver and tympanic over the underlying stomach, bronchial and tubular breath sounds, bronchovesicular and vesicular breath sounds
148
Abnormal Findings Anterior Thorax
abnormal breathing sounds, costal angle is widened, asymmetric and/or decreased respiratory excursion, same as posterior fremitus, asymmetry in percussion notes, areas of dullness or flatness over lung tissues, adventitious breath sounds
149
Abnormal Findings Posterior Thorax
barrel chest, increased anteroposterior to transverse diameter, thorax asymmetric, exaggerated spinal curvatures, spinal column deviates to one side, often accentuated when bending over, shoulders or hips not even, skin lesions, areas of hyperthermia, lumps, bulges, depressions, areas of tenderness, movable structures, asymmetric and/or decreased thorax expansion, decreased or absent fremitus, increased fremitus, asymmetry in percussion notes, areas of dullness or flatness over lung tissue, adventitious breath sounds, absence of breath sounds
150
Where do you hear bronchial sounds?
anteriorly over trachea
151
Where do you hear vesicular sounds?
Over peripheral lung, best heard at base of lungs
152
Where do you hear bronchovesicular sounds?
between the scapulae and lateral to the sternum at the 1st and 2nd intercostal
153
What is another name for acute confusion?
delirium
154
What is another name for chronic confusion?
dementia
155
Alzheimer's Disease
Progressive mental deterioration occurring in middle or old age, due to generalized degeneration of the brain
156
Delusions
a fixed belief that is either false, fanciful, or derived from deception.
157
Disorientation
the loss of proper bearings, or a state of mental confusion as to time, place, or identity.
158
Hallucinations
visually see, smell, hear or taste something that's not there
159
Prebycusis
generalized loss of hearing related to aging
160
Presbyopia
loss of elasticity of the lens and thus loss of ability to see close objects as a result of the aging process
161
Sensory perception
The organization and translation of stimuli into meaningful information
162
Sensory reception
process of receiving environmental stimuli
