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152 Cards in this Set
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percussed flat note
origin sound structure |
very dense tissue
flat muscle/bone |
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percussed dullness
origin sound structure |
more solid tissue
thud liver splean heart |
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percussed tympany
origin sound structure |
enclosed air
drum like gastric bubble in gut, puffed out cheek |
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percussed resonance
origin sound structure |
part air/solid
hollow normal over lung tissue |
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percussed hyperresonance
origin sound structure |
more air than normal
booming infant lung, hyperinflated lungdi |
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direct percussion
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hitting fingers directly on skin. like sinus examination
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indirect percussion
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put hand on pt and tap finger
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blunt percussion
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using a fist to beat on our own hand
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a stethascope does/doesnt amplify sounds
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does not. it just blocked out other sounds
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the ______ is used to hear high pitched sounds while the ______ is used for low pitch sounds
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diaphragm (fine crackles, breath sounds)
bell (heart murmer, bruits) |
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Gliiding joint
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Verrtabrea
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Ball and socket joint
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Unlimited rom in multiple directions fore example the hip and shoulder
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synovial joints
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aka diathrodial
joints lined with synovial fluid for lubrication |
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what kind of joint is the vertebrea
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gliding, synovial
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what kind of joints are at the hip and shoulder
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ball and socket joints, synovial
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biaxial joints
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synovial
movement along multiple planes but along one plane at a time eg: thumb |
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condylar
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synovial joint, flex extend, limited lateral movement eg kneee
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amphiarthoridal joint
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joints slightly moveable
PELVIS MANUBRIOSTERNAL |
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synarthoridal joint
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non moveable joint. separates bones with a thin layer of cartilage
CRAINIAL STRUCTURE |
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tendons
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bands of connective tissue
ATTATCH MUSCLE TO BONE non elastic if overstretched, will tear |
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synarthoridal joint
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non movable
sperates bones with thin layer of cartilage CRANIAL STRUCTURE |
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ligaments
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bands of connective tissue
ATTACH BONE TO BONE elastic tears easily |
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cartilage
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smooth resistant fiber
absorbs shock |
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crepitus
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crackling noise you can hear or feel
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three common medicines that effect bones
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ca supplements
asa antiinflammatory |
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smoking contributes to the development of which common disease in older females
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osteoporosis
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upon joint inspection inspect 4 charecteristics
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size
swelling shape deformeties |
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upon joint palpation, inspect 3 charecteristics
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effusion
heat redness |
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upon auscultation of the joint listen for
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crepitation
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upon muscle inspection, assess 6 charecteristics
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size
swelling shape contour symmetry involuntary movement |
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upon muscle palpation asess for 3 charecteristics
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tenderness
masses heat |
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what is the lovetts scale?
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love your muslces!
5+ is normal rom. unimpaired against gravity w/ full resistance 0: no evidence of muscle contraction |
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1+ lovetts
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trace
no joint motion and slight evidence of muscle contration |
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2+ lovetts
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poor
can complete ROM w/ gravity eliminated aka passive rom |
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3+ lovetts
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fair
can complete full ROM agains gravity |
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4+lovetts
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good
coan complete ROM against gravity w/ some resistance |
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hip make/break technique
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clietns upine and attempts to raise leg against resistance
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hamstrings/glutes/abductors/adductors make/break tech
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client sits and alternatively crosses legs
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quad make/break tech
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extend leg at knee from sitting position and examier attempts to flex knee by pushing down
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hamstrings make/break tech
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leg is bent with client in sittin position. client tries to bend knee while examiner attempts to straigthen
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phelans test
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A common test for diagnosing carpal tunnel syndrome. In a positive Phelan’s test, tingling or numbness is felt within one minute when the subject’s hands are held with the wrists flexed (usually at a 90° angle).
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tinels sign
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a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.
if nerves irritated=carpel tunnel syndrome. JCC |
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ankylosis
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s a stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease.
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baker cyst
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also known as a popliteal cyst, is a benign swelling of the semimembranous bursa found behind the knee joint
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contralateral
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on the opposite from another structure. Thus, the left arm is contralateral to the right arm, or the right leg.
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eversion
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the movement of the sole of the foot away from the median plane.
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fasciculation
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muscle twitch", is a small, local, involuntary muscle contraction and relaxation visible under the skin arising from the spontaneous discharge of a bundle of skeletal muscle fibers
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frozen shoulder
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a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain.
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goniometer
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an instrument that either measures angle or allows an object to be rotated to a precise angular position
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inversion
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movement of the sole towards the median plane (as when an ankle is twisted).
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ipsilatera
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on the same side as another structure. Thus, the left arm is ipsilateral to the left leg.
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lordosis
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inward curvature of a portion of the vertebral column. Sway back happens often when pregnant
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luxation
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occurs when bones in a joint become displaced or misaligned. It is often caused by a sudden impact to the joint. The ligaments always become damaged as a result of a dislocation.
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osteopenia
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a condition where bone mineral density is lower than normal.
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rotator cuff syndrome
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damage to the rotator cuff, is a part of the shoulder
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adhesive capsulitis
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aka frozen shoulder
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mediastium
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is a non-delineated group of structures in the thorax, surrounded by loose connective tissue. It is the central compartment of the thoracic cavity. It contains the heart, the great vessels of the heart, esophagus, trachea, phrenic nerve, cardiac nerve, thoracic duct, thymus, and lymph nodes of the central chest
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pleura
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the body cavity that surrounds the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally contains a small amount of pleural fluid.
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kyphoscoliosis
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describes an abnormal curvature of the spine in both a coronal and sagittal plane. It is a combination of kyphosis and scoliosis.b
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barrel chest patients look like..
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they're as wide as they are deep
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whose chest would be barrel shaped?
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someone with cmphasyma
hx chronially inflated lungs |
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your patients sternum and ribs protrude. what condition is this called ?
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pectus carinatum
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your patients chest is sunken. what is this called?
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pectus excavatum
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the apecies of lungs extend how many cm above clavicle?
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3-4cm
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during the lung assessment, you make sure to asses each of these lobes of lung on the anterior side
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RUL
RML RLL LEL LLL |
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during the posterior lung assessment, you are sure to asses each of these lobes
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RUL
LUL |
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sickle cell is prevelant in what race
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blacks
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TB has a high prevelence in which race
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asains
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Mr. Huang Ho is having NOC sweats, low grade afternoon fevers, and rust colored sputum. what do you suspect?
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TB
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what are the 4 A's of tobacco cessation?
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ASK about smoking each visit
ADVISE pt regularly ASSIST pt to set up stop date ARRANGE for f/u visit |
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pink frothy sputum could indicate what?
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pulmonary edema
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what is coining
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a vietnamese home remidey where someone rubs coins on the thorax in order to cure respiratory illness
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what can RA do to the spine?
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deform it
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flail chest is..
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a life-threatening medical condition
occurs when a segment of the chest wall bones breaks under extreme stress |
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your patient has a long bone fx. what blood issue could this person have?
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fx can cause release from inside bone content wich can cause embolism
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AP transfer ration should be..
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2:1
1:1=barrel chest AP=anterior/posterior |
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cheyne stokes
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an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea.
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hyperpnea
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increase depth of resp
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you perform a respiratory excursion on your patient. how far do you expect your thumbs to move?
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2-3cm
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what is a good phrase to asses frematis?
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99
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increased tactile frematis is due to...
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shit in your lungs- pnemonia, tumor
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your patient has emphasyma. you perform tactile frematis on him. what findings do you expect?
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decrease frematis r/t hallowness
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where do you expect to hear bronchial sounds?
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over the trachea
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inspiration</>expiration for bronchial sounds
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i shorter e
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describe bronchial sounds in the words of t. krass
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loud tubular sounds
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where are bronchovesicular sounds heard?
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angle of louis
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inspiration</>/=expiration bronchovesicular sounds
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=
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describe vesicular sounds in the words of t. krass
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like wind blowing through the trees
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explain voice sounds
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listen with scope while they say 99, 99
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what is bronchophony
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an abnormal clarity heard during voice sounds. when they say 99 it should be heard muffled but not clear
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what is egophony
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have the pt say ee ee ee. egophony occurs when it sounds like they're saying ay ay ay
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whispered pectoriloquy
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refers to an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields on a patient's back.[1]
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you are giving report on a pt whom you heard crackles in their lungs. what do you say?
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sounds are fine/medium/course.
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what is a common chronic dz in which one might hear crackles in the lungs
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CHF
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what are two types of wheezing
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sibilant
sonorus |
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sibilant wheezes are..
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high pitched musical noises
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sonorus wheezes are ..
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junky sounding lungs with emphasyma or pneumonia
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two common caueses of absent/diminshed breath sounds
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pneumothorax, obesityy
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your pt has high pitched inspiratory crowing sound. what is this called?
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stridor
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what are the 4 cranial bones
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frontal
parietal temporal occipital |
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what are the fucntions of our shnoz?
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olfaction
warming moisturizing filtering inspired air |
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internal nose has 3 structures
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septum
turbinates meatus |
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you have a patient of darkers skin. they have a dark bluish line in their mouth. what do you think?
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normal fiding
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you're assessing an asain man. his uvula looks like it's split down the middle! what do you think?
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normal fiding
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have the person stick their tounge out. and say ah. uvula goes to the left. what cranial nerves could there be a problem with?
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9/10
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what does a normal thyroid gland feel like?
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smooth and rubbery
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pre auricular lymph drains
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ducts from forehead and upper face
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post auricular lymph drains
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parietal area of head and part of ear
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parotid lyph drains
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side of head and parotid glands, forehead, cheek, eyelids, ear, nose, upper lip, eustachian tubes
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submandibular lymph nodes drain
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chin upper lip cheek nose teeth eye lids part of tongue and floor of mouth
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submental lymph drains..
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gums floor of mouth and part of tounge
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anterior superficial cervical chain lymph
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skin/neck drainage
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posterior superficial cerviacl chain lymph drains
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subclavian
laterocervical anterothoracic internal mammary regions |
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deep cervical chain lymph drains
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larynx
thyroid trach upper part of esophagus |
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supraclavicular lymph drains
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breast
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axillary lymph drains
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upper extremity
deltoid anterior wall of chest breasts |
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epitrochlear lymph drains
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ulner artery
fingers |
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inguinal lymph drains
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lower extremity
external enitalia anterior abd wall |
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popliteal lymph drains
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saphenous vein
knee joint arteries of the leg |
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cranial nerve 7 innervated
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the face. controls facial expression
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the thyroid controls..
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controls how quickly the body uses energy, makes proteins, and controls how sensitive the body should be to other hormones.
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cerumen
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ear wax
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exotosis
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the formation of new bone on the surface of a bone
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coopers ligament
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ligaments in breast that help maintain structure
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gynocomastis
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breasts in young men or old men r/t hormone indifference
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4 positions for a breast exam
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sitting with arms at side
arms overhead hands pressed on hip arms extended straight overhead as client leans forward |
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4 areas to asses on breasts
SSSSC |
size
symmetry shape skin color |
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5 areas to assess on nipples
CDSST |
color
dishcarge size shape texture |
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what are three methods of palpation of the breast
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verticle strip method
concerntric circles method wedge method |
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when you palpate a breast.. what are 6 charecteristics to assess for?
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temp
elasticicty tenderness masses nipples axillary lymph |
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colostrum
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thick yellow fluid
precursor for milk protein and lactose |
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cyclic breast pain is common/uncommon
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common
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how often should women 20-39 yrs have clinical breast exams?
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q3yr
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women over 4o should have CBE how often?
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qyr close to the same time each year
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Problem solving methods:
Reflexive- Trail and Error- Intuituve- Scientific- |
Reflexive- automative response not considering assesment factors. ex. pt w/ fever give tylenol
Trial and error- random thinking. Free association Intuitive- insight into patients personality and what will happen next Scientific Method- BEST nursing process. uses critical thinking. asses, diagnose, plan, implement, evaluate |
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In health assesment EBP is based on ______ and ______ prefernce
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In health assesment EBP is based on RESEARCH and PATIENT PREFERENCE
(will take into account nurses skill level as well as available information about the patient) |
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Assessment:
Subjective data- Objective data- Primary sourse data- Secondary course data |
Assessment:
Subjective data- symptoms client tells you Objective data-signs (bp, labs) Primary sourse data- client tells Secondary course data- other peopel tell the nurse about the clinent ( family, other staff) |
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Nursing Diagnosis is a statment htat describes the H_M_N R__S__P__N__E that the nurse can leagally identify and for which the nurse can order definitive interventions to maintain health
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Human Response
Reasons Nursing Diagnosis? |
1. define nursing profession
2. tool in reasearch and education 3. increases acountability 4.defines nurses domain of knowledge |
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Planning during step 3 of the nursing process should be
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1. patient centered
2. goal directed 3. blueprint for action 4. long and short term goals |
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Implamentation (step 4 of nursing process) includes
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Nurses actions or interventions. These must be specific and MEASUREABLE activites treatments, assessments, teachings..
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Theraputic use of self is a communication technique in which the interviewer uses personal qualities to support the cleitns perspective or feelings by finding a communication connection.
Three ways to enhance theraputic use of self: |
1. Empathy
2. Demonstrate Respect 3. Give Recognintion |
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What happens during each of the following phases of the interview?
Introductory Working Termination |
Introductory- introduce, build rapport, make a contract/outline for what will be happening
Working- fufill contract and collect data. ask open ended questions and closed questions to get facts Terminationg- make sure data is correct. summerize. |
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Parts of Health History
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CC, History of Present illness, Past medical History, Current Health info,
Family Histroy, Review of Symptoms |
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Chief Complant
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reason for visit, short statment in clients own fords for their reason of seeking care. Primary source data, put in quotes.
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History of present illness
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elaboration of CC.
1. symptoms analysis OPQRST 2. Pertinent Negatives 3. Relevent family infor 4. Funcation assesment- how present problem effects ADL (bath) and IADL ( checkbook balance) |
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Past Medical History
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Childhood, Illness, accidents, injuries, opecations, major actue and chronic illnesses, immunizations
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Current Health Info
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Allergies, Habits (smoke, drink), Medications, alternative therapies
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ROS looks at which systems
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1. physical
2. sociological 3. physological 4, developmental 5. nutritional |
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The LEARN modle is a guide to overcome barriers in cross pultural communication. What does LEARN stand for?
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Listen with empathy and understinding for clients perception of the prblem
Explain your perception of the problem Acknowledge and discuss the differences and similarities Recommend a course of action Negotiate and agree |
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body types:
Mesomorphic: Ectomorphic Endomorphin |
Mesomorphic- average height and well developed muscles
Ectomorphic- tall willowy. muscles and fat not well developed Endomorphic- short stocky. most likely to be obese. stomach high in abdomen |
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Mental status assesment
ABCT |
Apperance
Behavior- level of conciousness, facial expression, speech, mood and affect Congnition Thought process |
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Common nail abnormailities
nail thickening- onycholysis- koilonychia- clubbing- beau's lines- dyschromia- |
•nail thickening- arterial insufficiency
•onycholysis- separation of nail from bed due to fungal infection or chemo •kiolonychia- spoon nail. anemia iron deficiency •clubbing- sign of chronic hypoxia, angle of nail base >180 emphysema and heart disease •beau's lines- horizontal grooves in nail from |
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