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109 Cards in this Set

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Edema
excessive amount of fluid in the tissues

an abnormal finding
Erythema
a reddened area

can be due to infections or inflammation
what can you be sure of in older adults?
assess support system and ADL's,
observe clients energy level during the physical exam and provide rest if needed.

obtain feeback to be sure the pt is seeing and hearing you adequately
REDA/COCA

what do you assess them for?
Redness, Edema, Drainage, Approximation= assessing wound

Color, Odor, Consistency, Amount= Assessing gauze
common complaint with skin conditions
pruitis (itching)
4 factors that affect skin
exposure, age, hyperthyroidism and other endocrine disorders and impaired circulation
misplaced breath sounds indicate...

diminished? adventitious?
constriction of flow

diminished= heard with poor inspiratory effort

adventitious= heard over normal breath sounds
fourth heart sound (s4)
normal in trained athletes and old people

s3 and s4 best heard at apical site using bell of stethoscope
complete physical assessment
interview and head to toe exam of every body system

ex: done at outpatient appts, annual physicals, admission to inpatient setting
aspects of general survey
appearance and behavior
body type and posture
speech
dress and hygiene
mental state
vital signs
height and weight
vascular system
consists of a network of arteries (carry blood away from heart) and veins that transport o2, co2 and nutrients to cells of body
ptosis
drooping eyelid

maybe caused by a stroke or neurological injury
CVA
costovertebral angle
tachypenea
rapid respiration

vesicular breath sounds are low

bronchial is high
tactile fremitis
vibration more intense in areas of tissue consolidation

-test by saying 99 outloud [brohophony]
thrush
a fungal infection
borborymus
hunger pains
arous sinils
white ring circling cornea
leukoplakia
white patches that bleed and dont scrape off

can be cancerous
kussmauls respirations
rapid, deep breathing without pauses for greater than 20 mins
aortic valve
located in the 2nd ICS and R sternal border
pneumathorax
punctured lung
barrel chest
occurs in ppl with COPD

mitral valve is assesed in apex
resonance
heard over normal lung tissue
strabismus
cross-eyed- eyes dont focus on same things
propulsive gait
abnormal gait where person leans forward
what are the 5 different types of abnormal gaits
propulsive gait
scissors gait
spastic gait
steppage gait
waddling gait
hyperresonance
heard if there is increased air in lung or pleural space
tricuspid valve
located at the 4th ICS on L sternal border
pectus excavatum
deformity- sunken or funnel chest
epistaxis
acute hemorrhage from the nostril, nasal cavity, or nasopharynx (nosebleed)
pallor
poor circulation or low hemoglobin

best assessed at palms, nail beds, soles on feel, conjuctive, etc
orthopnea
difficulty breathing while lying down
diplopia
double vision
pruitis
common complaint in skin conditions
exopthalus
failure of pupils to accomodate
where is the apex of the heart located
5th ICS--mitral valve
where is the base of the heart located
2nd ICS-- pulmonic valve
tracheal breath sounds
high putched inspiration is less than expiration
IOM report
med errors 8th leading cause of death due to system or process failure
paresthesia
numbness or stinging from injury to nerves
3 essential component of nursing assessment
history, assessment and test
4 things to notice when assessing skin color
cyanosis, pallor, jaundice, erythema
cyanosis
seen in lips with hypoxia

also seen in extremities esp. hand and feet after exposure to cold
normal capillary refill
less than 3 seconds
expothalmus
protrusion of eye
crackles
air moving through fluid, heard in inspiration
biots respirations
shorter apnea, 10-20 sec
tenting
skin stays up when checking turgor
rhonchi
heard on expiration
sentinel event
unexpected occurrence involving death or serious injury
jaundice
yellow skin, due to liver problems
pulse pressure
systolic minus diastolic
pallor
poor circulation or low hemoglobin

best assessed at palms, nail beds, soles of feet, etc
resonance
over normal lung tissue
pulmonary/systemic arteries
pulmonary arteries carry oxygen-depleted blood from the right ventricle to the lungs

systemic arteries carry oxygenated blood from the left ventricle to the body periphery
NANDA
North American Nursing Diagnosis Association
veins

pulmonary vs systemic
carry blood toward herat

pulmonary veins transport oxygenated blood from the lungs to the left atrium

systemic veins return oxygen-depleted blood from the periphery to right atrium of heart
restraint

2 forms
any device that restricts a pt
s voluntary movement or access to to his body and that can't easily be removed by pt

1. mechanical [ex. siderail: ambularm and integral bed alarm]
2. chemical [ex. medications: sedatives, psychotropic agents]
restraint imposed mobility can cause
pressure ulcers, contractures
5 steps of nursing process
assessment, diagnosis, planning, implementation, evaluation
pulse deficit
apical minus radial
vision

myopia

hyperopia

presbyopia
20/20 vision isnt reached until age 6 or 7

myopia- diminished distant vision

hyperopia- diminished near vision

presbyopia- in pt 45 yrs and older
PERRLA
pupils equal, round, reactive to light and accomodation
nursing has the highest rate of back injuries even higher than
construction workers
fall
80% involve people age 65 and older

clients at risk for falls, repeat fall assessment every 8hours and increase frequency of rounds
JCAHO patient safety goals
1. improve the accuracy of patient identification
2. improve effectiveness of communication among caregivers
3. improve safety of using high-alert mediators
4. eliminate wrong-site, wrong pt, and wrong procedure surgery
5. improve safety of using pumps
6. improve effectiveness of clinical alarm system
4 major safety hazards in community
motor vehicle accidents, pathogens, pollution, and electrical storms
except for motor vehicle accidents, most fatal accidents occur in
the home. the leading causes of death include poisoning, falls, fires and burns, and suffocation by ingested objects
motor pathways

transmit...
information between brain and muscles and the muscles control movements of the skeleton
sensory function
includes light touch, pain, temperature vibration, position sense, stereognosis (recognize solid forms), graphesthesia (recognize outlines, numbers, or symbols)

coordinates the function of the skeleton and muscle
Level of consciousness (LOC)
includes arousal and orientation

an alert client responds to auditory stimuli, tactile stimuli or painful stimuli

orientation- refers to awareness of time, place and person
cerebral function

refers to...
the client intellectual and behavioral functioning

it includes:
level of consciousness, mental status, cognitive functioning, and communication
neurological system

control...
the function of all body systems and allows interaction with the external world. its work is carried out through the transmission of chemical and electrical signals between the body and the brain
how do you assess the peripheral vascular system?
1. measure blood pressure
2. palpating the peripheral pulses
3. inspecting and performing test for adequate perfusion
bruit
turbulent blood flow through carotid artery and produces a whoosing sound

palpating neck fro thrill further confirm turbulent flow

listen over aorta and renal, iliac, and femoral arteries for bruits
what do you do last when assessing the abdomen
percussion and palpation

examine sensitive areas last

clamp off NG tubes if present
variscosities
rope-like distended veins
jugular veins and JVD
jugular veins return blood from brain to superior vena cava

jugular venous distention (JVD) is seen when the right side of heart is congested due to inadequate pump function
arteries vs veins
arteries are high pressure systems with several palpable pulse sites

veins are low pressure system with valves that return blood to the heart via the continuing pressure from arterial system and pumping action of adjacent muscles
second heart sound (s2)
corresponds to closure of the semilunar valves

marks the beginning of diastole "dub" higher in pitch and shorter than s1

loudest at aortic and pulmonic areas
normal variations of lesions
lesions- variation in pigment

milia, nevi (moles), freckles, birthmarks, skin tags, and striae (stretch marks)
focused physical assessment
performed to obtain data about an actual, potential, or possible problem that has been identified
thrill/murmurs
thrill- vibration or pulsation palpated in any area except PMI usually associated with abnormal blood flow and usually has an accompanying murmur

murmurs- additional heart sound best heard at Erbs point
first heart sound (s1)
results from closure of valves between the atria and ventricles. loudest over mitral and tricuspid areas

marks beginning of systole (lub) a dull, low pitched sound
hirsutism
excess facial or trunk hair may be due to endocrine disorder or steriods
an upright position allows the client to fully expand...

useful for assessing...
expand the lungs

assess vital signs
systole/diastole
systole- atrias are contracting (emptying)

diastole- relaxation (filling) of ventricles
4 skills used in physical exam

and sometimes...
inspection- look, begins at first encounter

palpation- touch

percussion- tap (indirection is used more frequently)

ascultation- listen/hearing
-direct- without instrument
-indirect- with stethoscope

sometimes olfaction- smell
precordium and PMI
precordium- area of chest over heart, for visible pulsation

a small pulsation at the 5th ICD mid-clavicular line also known as Point of Maximal Impulse (PMI) is normal
bronchovesicular breath sounds
medium pitched with an equal inspiratory and expiratory phase

best heard over 1st and 2nd ICS
capillary/ venous systems
capillary level is where oxygen is delivered to tissues
capillary/ venous systems
capillary level is where oxygen is delivered to tissues

venous system collects oxygen-depleted blood and returns it to the right atrium of the heart to begin circuit again
cardiovascular system

consists of...
heart (muscle that pumps blood throughout the body)

blood vessels (pulmary and systemic circulation)
primary/secondary lesions
primary- develop as a result of disease or irritation

secondary- develop from primary lesions as a result of continued illness, exposure, injury or infection (ex. crust from popped pimples)
oxygen depleted blood

pulmonary circulation?
from the heart to the blood enters the systemic circulation

P.C.= circulates from the heart into the lungs, where oxygenated then back to the heart
warning signs of malignant lesions by thinking of letters ABCDE
A= asymmetry
B= border irregulation
C= color variation
D= diameter greater than .5cm
E= elevation above skin surface
R.A.C.E.
Rescue the pt
Activate the alarm
Confine the fire
Extinguish the fire
BMI
body mass index

evaluates relationship btwn height and weight
the heart

order to ausculate? perform in 3 positions?
perform in 3 positions: sitting, supine, L lateral recumbant

to throughly assess heart auscultate in orderly fashion starting with aortic

Aortic (right side)
Pulmonic (left)
Tricuspid (left)
Mitral (left)
nursing assessments
focus on clients functional abilities and physical responses to illness and other stressors
kyphosis/ scoliosis
kyphosis- excessive curvature of thoracic spine

scoliosis- lateral curvature of spine
bronchial breath sounds
loud, high pitched, tubular sounds, inspiration is of longer duration than expiration

heard best over trachea
alopecia
hair loss
largest chamber of heart
left ventricle

pumps blood into the systemic circulation via the arterial system
what size is the arterioposterior diameter compared to the lateral diameter
twice the size of the lateral diameter
variation in skin color commonly seen in infants

mongolian spots

capillary hemangiomas
normal skin is warm and dry

mongolian spots= blue-black areas seen on the lower back and buttocks of African American, Native American and Asian babies

Capillary hemangiomas- "stork bite" are small irregular pink-red areas that are often seen around the face and neck in newborns. disappear in infancy
third heart sound (s3)
immediately heard after s2 follows kenTUCky

normal in young children and adolescents when sitting/lying. but disappears when they stand.

if not... its abnormal and represents heart failure or volume overload
vesicular breath sounds
soft, low pitched, breezy sounds with a lengthy inspiratory phase and a short expiratory phase

best heard over lung fields