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109 Cards in this Set
- Front
- Back
Edema
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excessive amount of fluid in the tissues
an abnormal finding |
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Erythema
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a reddened area
can be due to infections or inflammation |
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what can you be sure of in older adults?
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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 |
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REDA/COCA
what do you assess them for? |
Redness, Edema, Drainage, Approximation= assessing wound
Color, Odor, Consistency, Amount= Assessing gauze |
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common complaint with skin conditions
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pruitis (itching)
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4 factors that affect skin
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exposure, age, hyperthyroidism and other endocrine disorders and impaired circulation
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misplaced breath sounds indicate...
diminished? adventitious? |
constriction of flow
diminished= heard with poor inspiratory effort adventitious= heard over normal breath sounds |
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fourth heart sound (s4)
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normal in trained athletes and old people
s3 and s4 best heard at apical site using bell of stethoscope |
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complete physical assessment
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interview and head to toe exam of every body system
ex: done at outpatient appts, annual physicals, admission to inpatient setting |
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aspects of general survey
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appearance and behavior
body type and posture speech dress and hygiene mental state vital signs height and weight |
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vascular system
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consists of a network of arteries (carry blood away from heart) and veins that transport o2, co2 and nutrients to cells of body
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ptosis
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drooping eyelid
maybe caused by a stroke or neurological injury |
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CVA
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costovertebral angle
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tachypenea
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rapid respiration
vesicular breath sounds are low bronchial is high |
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tactile fremitis
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vibration more intense in areas of tissue consolidation
-test by saying 99 outloud [brohophony] |
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thrush
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a fungal infection
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borborymus
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hunger pains
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arous sinils
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white ring circling cornea
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leukoplakia
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white patches that bleed and dont scrape off
can be cancerous |
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kussmauls respirations
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rapid, deep breathing without pauses for greater than 20 mins
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aortic valve
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located in the 2nd ICS and R sternal border
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pneumathorax
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punctured lung
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barrel chest
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occurs in ppl with COPD
mitral valve is assesed in apex |
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resonance
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heard over normal lung tissue
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strabismus
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cross-eyed- eyes dont focus on same things
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propulsive gait
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abnormal gait where person leans forward
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what are the 5 different types of abnormal gaits
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propulsive gait
scissors gait spastic gait steppage gait waddling gait |
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hyperresonance
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heard if there is increased air in lung or pleural space
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tricuspid valve
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located at the 4th ICS on L sternal border
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pectus excavatum
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deformity- sunken or funnel chest
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epistaxis
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acute hemorrhage from the nostril, nasal cavity, or nasopharynx (nosebleed)
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pallor
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poor circulation or low hemoglobin
best assessed at palms, nail beds, soles on feel, conjuctive, etc |
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orthopnea
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difficulty breathing while lying down
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diplopia
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double vision
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pruitis
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common complaint in skin conditions
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exopthalus
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failure of pupils to accomodate
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where is the apex of the heart located
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5th ICS--mitral valve
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where is the base of the heart located
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2nd ICS-- pulmonic valve
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tracheal breath sounds
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high putched inspiration is less than expiration
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IOM report
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med errors 8th leading cause of death due to system or process failure
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paresthesia
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numbness or stinging from injury to nerves
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3 essential component of nursing assessment
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history, assessment and test
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4 things to notice when assessing skin color
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cyanosis, pallor, jaundice, erythema
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cyanosis
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seen in lips with hypoxia
also seen in extremities esp. hand and feet after exposure to cold |
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normal capillary refill
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less than 3 seconds
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expothalmus
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protrusion of eye
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crackles
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air moving through fluid, heard in inspiration
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biots respirations
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shorter apnea, 10-20 sec
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tenting
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skin stays up when checking turgor
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rhonchi
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heard on expiration
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sentinel event
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unexpected occurrence involving death or serious injury
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jaundice
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yellow skin, due to liver problems
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pulse pressure
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systolic minus diastolic
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pallor
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poor circulation or low hemoglobin
best assessed at palms, nail beds, soles of feet, etc |
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resonance
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over normal lung tissue
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pulmonary/systemic arteries
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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 |
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NANDA
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North American Nursing Diagnosis Association
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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 |
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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] |
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restraint imposed mobility can cause
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pressure ulcers, contractures
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5 steps of nursing process
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assessment, diagnosis, planning, implementation, evaluation
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pulse deficit
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apical minus radial
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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 |
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PERRLA
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pupils equal, round, reactive to light and accomodation
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nursing has the highest rate of back injuries even higher than
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construction workers
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fall
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80% involve people age 65 and older
clients at risk for falls, repeat fall assessment every 8hours and increase frequency of rounds |
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JCAHO patient safety goals
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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 |
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4 major safety hazards in community
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motor vehicle accidents, pathogens, pollution, and electrical storms
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except for motor vehicle accidents, most fatal accidents occur in
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the home. the leading causes of death include poisoning, falls, fires and burns, and suffocation by ingested objects
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motor pathways
transmit... |
information between brain and muscles and the muscles control movements of the skeleton
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sensory function
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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 |
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Level of consciousness (LOC)
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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 |
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cerebral function
refers to... |
the client intellectual and behavioral functioning
it includes: level of consciousness, mental status, cognitive functioning, and communication |
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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
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how do you assess the peripheral vascular system?
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1. measure blood pressure
2. palpating the peripheral pulses 3. inspecting and performing test for adequate perfusion |
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bruit
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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 |
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what do you do last when assessing the abdomen
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percussion and palpation
examine sensitive areas last clamp off NG tubes if present |
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variscosities
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rope-like distended veins
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jugular veins and JVD
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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 |
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arteries vs veins
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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 |
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second heart sound (s2)
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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 |
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normal variations of lesions
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lesions- variation in pigment
milia, nevi (moles), freckles, birthmarks, skin tags, and striae (stretch marks) |
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focused physical assessment
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performed to obtain data about an actual, potential, or possible problem that has been identified
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thrill/murmurs
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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 |
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first heart sound (s1)
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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 |
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hirsutism
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excess facial or trunk hair may be due to endocrine disorder or steriods
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an upright position allows the client to fully expand...
useful for assessing... |
expand the lungs
assess vital signs |
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systole/diastole
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systole- atrias are contracting (emptying)
diastole- relaxation (filling) of ventricles |
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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 |
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precordium and PMI
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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 |
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bronchovesicular breath sounds
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medium pitched with an equal inspiratory and expiratory phase
best heard over 1st and 2nd ICS |
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capillary/ venous systems
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capillary level is where oxygen is delivered to tissues
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capillary/ venous systems
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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 |
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cardiovascular system
consists of... |
heart (muscle that pumps blood throughout the body)
blood vessels (pulmary and systemic circulation) |
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primary/secondary lesions
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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) |
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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 |
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warning signs of malignant lesions by thinking of letters ABCDE
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A= asymmetry
B= border irregulation C= color variation D= diameter greater than .5cm E= elevation above skin surface |
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R.A.C.E.
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Rescue the pt
Activate the alarm Confine the fire Extinguish the fire |
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BMI
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body mass index
evaluates relationship btwn height and weight |
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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) |
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nursing assessments
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focus on clients functional abilities and physical responses to illness and other stressors
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kyphosis/ scoliosis
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kyphosis- excessive curvature of thoracic spine
scoliosis- lateral curvature of spine |
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bronchial breath sounds
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loud, high pitched, tubular sounds, inspiration is of longer duration than expiration
heard best over trachea |
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alopecia
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hair loss
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largest chamber of heart
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left ventricle
pumps blood into the systemic circulation via the arterial system |
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what size is the arterioposterior diameter compared to the lateral diameter
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twice the size of the lateral diameter
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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 |
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third heart sound (s3)
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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 |
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vesicular breath sounds
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soft, low pitched, breezy sounds with a lengthy inspiratory phase and a short expiratory phase
best heard over lung fields |