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122 Cards in this Set
- Front
- Back
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This is the standard tool used when serial assessments are done after a cerebral vascular accident (stroke)?
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Glasgow Coma Scale (GCS)
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When a patient is unable to comprehend simple direction this communication problem is known as?
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Receptive Aphasia
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The redness that usually comes from irritation or inflammation
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ERYTHEMA
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How are normal pupil assessment recorded?
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PERRLA - PUPILS, EQUAL, ROUND, REACTIVE, to LIGHT and ACCOMMODATION
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What are the best verbal responses on the GCS?
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Best-Eye
Best Verbal Best Motor |
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The patient is able to understand, but has difficulty verbalizing effectively. This is known as?
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Expressive Aphasia
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This occurs when the skin color appears pale with hypoxia and anemia?
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PALLOR
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A sign of chronic hypoxia with swelling in the nails that flatten the profile angle 180 degree or less.
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CLUBBING
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Test that measure constriction or dilation of pupils when objects are close or at a distance.
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ACCOMMODATION
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How are bruits detected?
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By placing the stetoscope over the major blood vessels, e.g. carotid artery.
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Problems with the temporal mandibular joint (TMJ)
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CREPITUS
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What test discriminate between bone conduction and air conduction of sound
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RINNIE TEST
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I evaluate the lateralization of sound
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WEBER TEST
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Which conduction of sound is greater: bone or air?
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AIR CONDUCTION
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What instrument is used to screen for hearing?
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AUDIOMETER
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What is the major concern when examining the mouth?
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ABNORMALITIES that might impede the ability to chew, swallow, or taste food.
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What are abnormal arterial sounds called?
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BRUITS
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What are bruits caused by?
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INCREASED TURBULENCE OF BLOOD FLOW
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How is the height of jugular venous pressure measured?
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IN RELATION TO THE 2ND INTERCOSTAL SPACE
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What is the normal height of jugular venous pressure?
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LESS THAN 3cm AT A 45 DEGREE ANGLE
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What is the skin a reflexion of?
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THE BODY'S NUTRITION AND METABOLISM
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How do you examine the skin?
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INSPECTION AND PALPATION
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What do you assess the skin for?
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COLOR, MOISTURE, TEMPERATURE, TEXTURE AND HYGIENE
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What is a decreased supply of oxygen called?
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HYPOXIA
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I am observed in liver disease and causes the yellowing of skin color?
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JAUNDICE
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I am drainage from a wound, what am I?
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EXUDATE
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I am caused by accidents, pressure or surgeries, what am I?
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WOUND
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I am indicated by colors such as creamy, yellow or green. What am I?
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INFECTION
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I am indicated by black, brown or gray coloring. What am I?
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NECROSIS
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How is the amount of fluid tested in tissues?
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by checking SKIN TURGOR
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I am an abnormality in the skin as a result of injury or disease.
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LESION
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What are we looking for when assessing lesion?
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appeareance of borders, size, color, type and location.
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What is skin turgor?
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Rigidity or tension of the skin
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I am checking by pinching the anterior chest and the medial arm. What am I looking for?
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SKIN TURGOR
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What are the four major landmarks on the precordium?
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AORTIC,PULMONIC, TRICUSPID, AND MITRAL
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Where is the aortic located?
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2nd INTERCOSTAL SPACE, RIGHT STERNAL BORDER
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Where is the pulmonic located?
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2nd INTERCOSTAL SPACE, LEFT STERNAL BORDER
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Where is the tricuspid located?
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5th INTERCOSTAL SPACE, LEFT STERNAL BORDER
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Where is the mitral area located?
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5th INTERCOSTAL SPACE, JUST MEDIAL TO THE MIDCLAVICULAR LINE
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Inspection, palpation and auscultation are the three basic techniques used to assess what?
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THE PRECORDIUM & VASCULATURE
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What does PMI mean?
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POINT of MAXIMAL IMPULSE
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What is PMI?
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A visible pulsation that occurs with ventricular contraction as the left side of the heart strikes the anterior chest wall.
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What is the period from the beginning of S1 to the beginning of S2 called?
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SYSTOLE
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What is another term for systole?
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VENTRICULAR CONTRACTION
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What does normal heart sounds include?
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S1 & S2 RESPECTIVELY
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What is another term for diastole?
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VENTRICULAR RELAXATION
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What is the period from the beginning of S2 to the next ventricular contraction called?
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DIASTOLE
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Which sound is the "lub?"
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S1
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Which sound is the "dub"?
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S2
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When is S1 LOUDEST?
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WHEN THE MITRAL AND TRICUSPID VALVES CLOSE
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When is it easiest to differenciate between S1 & S2?
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WHEN THE HEART RATE IS SLOW
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Which sound is shorter?
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SYSTOLE
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How can you distinguish between S1 &S2 when the heart rate is faster?
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FEEL THE CLIENT'S CAROTID PULSE WHEN LISTENING TO THE HEART
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When is S1 said to be split?
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WHEN AN AUDIBLE DIFFERENCE IS DETECTED IN CLOSURE OF THE TWO VALVES
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When is S2 loudest?
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WHEN THE AORTIC AND PULMONIC VALVES CLOSE
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I am a vibrating sound that results from turbulent blood flow through the heart, esp. across the valves
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MURMUR
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What is a gallop?
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AUSCULTATION OF S3 & S4 SOUNDS THAT IS CLEAREST AT THE APEX WHEN CLIENT IS ON THEIR LEFT SIDE
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What are extra heart sounds?
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S3 & S4
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I am normal in young adults and children, but signifies heart failure in adults
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S3
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I am thought to result from a stiffening of the left ventricle
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S4
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What four major areas should respiratory history focus on?
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Risk factors for lung disease,
Signs & Symptoms Respiratory dysfunction, Impact of of respiratory on ADL, and adaptive measures for any respiratory dysfunction. |
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What is important in determining the acuteness of client's problem?
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A survey of skin color,
Respiratory difficulty, and Position client takes to breathe. |
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What does inspection of the respiratory exam focus on?
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Breathing patterns, Observations of nails & skin
Signs of labored breathing Configurations of the thorax |
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I am used to describe the distance between the sternum and the vertebral column, drawn as a straight line through the thorax.
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THE ANTERIOR-POSTERIOR (AP) DIAMETER
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How is the shape of the thorax examined?
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By having the client sit in an upright position
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I am abnormal breathing sounds
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ADVENTITIOUS BREATHING SOUNDS
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What are the major adventitious breath sounds?
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CRACKLES, WHEEZES & FRICTION RUBS
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Where are vesicular breath sounds normally heard?
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OVER ALL AREAS OF THE LUNGS EXCEPT MAJOR AIRWAYS
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I am high pitched and loud with a hollow quality often like a air through a pipe
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BRONCHIAL BREATH SOUNDS
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Bronchial, bronchovesicular and vesicular are classified as
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NORMAL BREATH SOUNDS
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What is normal and heard over the trachea?
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BRONCHIAL BREATH SOUNDS
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What are conditions that constitute abnormal bronchial sounds?
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pneumonia, pleural effusion, tumors and atelectasis.
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I am normally heard between two breath sounds but a softer and lower pitch
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BRONCHOVESICULAR BREATH SOUNDS
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In bronchial breath sounds, which is longer & louder: inspiration or expiration?
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EXPIRATION
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I am described as soft and breezy
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VESICULAR BREATH SOUNDS
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What is the order when examening the bowels?
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INSPECT
AUSCULTATE PERCUSSION PALPATION |
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What organs are located in the upper right quadrant?
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LIVER, GALLBLADDER, DUODENUM, PANCREAS (HEAD), RT. ADRENAL, UPPER LOBE OF RT. KIDNEY, HEPATIC FLEXION OF COLON, & PARTS OF BOTH THE ASCENDING / DESCENDING COLON
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Why do we not palpate the abdomen of a client. complaining of pain?
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DOING SO CAN CAUSE RUPTURE IN AN INFLAMED ORGAN
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Where does the uterus and urinary bladder fall in proximity to the 4 quadrants?
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IN THE LOWER MIDLINE
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What is percussion used to detect?
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THE LOCATION OF ORGANS NOT NORMALLY PALPABLE TO GIVE CLUES OF MASSES UNDERLYING THE SKIN
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What sound do you hear when over the liver?
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DULL
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Where is the liver percussed?
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AT THE RT. MIDCLAVICULAR & MIDSTERNAL LINES
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Where is tympany generally present?
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OVER THE INTESTINE
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Why is light palpation performed?
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TO OBTAIN INFO. ABOUT PAIN AND DISCOMFORT
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What organs are located in the lower left quadrant?
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SIGMOID COLON, LOWER KIDNEY LOBE, LEFT OVARIES, LFT. FALLOPIAN TUBES, LFT. URETERS, PART OF THE DESCENDING COLON, LEFT SPERMATIC CORD & PART OF THE UTERUS (IF ENLARGED)
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When working with the female client, what ques. should you ask?
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...OF MENSTRUATION,
PREGNACIES & # OF CHILDREN |
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When inspecting the female external organs, what does bright red color or areas of excoriation mean?
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INFECTION OR IRRITATION
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What is poor peripheral circulation associated with?
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HAIR LOSS, SKIN DISCOLORATION AND SCALING
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What problems can be associated with poor venous supply?
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EDEMA, CHRONIC PAIN, SLOW HEALING ULCERS, WARMTH, BROWN PIGMENTATION & FLAKY DERMATITIS
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What do we look for when palpating arterial pulses?
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RATE, RHYTHM, AMPLITUDE & SYMMETRY
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What is located in the upper left quadrant?
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Left Liver Lobe
Stomach Spleen Pancreas Upper left Kidney Lobe left Adrenal Gland Splenic flexure of colon Parts of the transverse/descending colon |
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What is located in the lower right quadrant?
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Cecum
Appendix, Rt. Ovaries, Fallopian tube, Ureters, Spematic cord, Parts of the Uterus (if enlarged) |
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Why is examining the testicular important?
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FOR EARLY DETECTION OF TESTICULAR CANCER
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What questions do you ask male clients?
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THAT OF ROUTINE TESTICULAR SELF EXAMS & CONCERNS OF SEXUAL FUNCTION
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What is EDEMA?
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Fluid accumulation in the tissues.
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A simple test of circulation using the nailbeds is called
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CAPILLARY REFILL TIME
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How long is capillary refill time?
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3 SECONDS
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Where should you press to assess for edema?
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BEHIND THE MEDIAL MALLEOLUS, OVER THE DORSUM OF THE FOOT & OVER THE SHIN
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Where do you assess a bedridden client for edema?
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THE BACK & THE SACRUM
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What is considered a general range of abnormal joint motion?
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GREATER THAN 10% REDUCTION
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When is it considered an emergency situation when assessing pulses?
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IF THE PERIHERAL PULSE IS NEWLY ABSENT
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What does CMS stand for?
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CIRCULATION
MOVEMENT SENSATION |
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When is CMS evaluated?
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WHEN AN ACUTE PROBLEM IS NOTED WITH LIMBS
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What do we assess circulation by?
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COLOR, TEMPERATURE, PULSES & CAPILLARY REFILL
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How do we assess sensation?
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BY ASKING CLIENT TO SAY WHEN HE/SHE FEELS THE TOUCH
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How do we assess movement?
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BY ASKING THE CLIENT TO VOLUNTARILY MOVE THE EXTREMITY
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The sensation of numbness and tingling is known as?
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PARESTHESIAS
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How do we test for reflex?
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BY TAPPING VARIOUS TENDONS IN THE BODY TO ELICIT THE APPROPRIATE REFLEX ARC RESPONSE
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I am sensory fibers from a single spinal nerve that serve particular skin surfaces
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DERMATOMES
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Why are dermatomes used?
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TO EVLAUATE SENSORY FUNCTION FOR HIGH RISK INDIVIDUALS
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What is the grading scale for pulses?
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Ranges from 0 to 4+
0 = Absent 1 = Diminished; thready; easily obliterated 2+ = Normal; not easily obliterated 3+ = Increased; full volume 4+ = Bounding; hyperkinetic |
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When concluding the interview, how does asking the client if there is anything they would like to discuss help?
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You can learn important info.
It invites the client to add info. you may overlooked or did not anticipate. |
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What should you do before formal closure?
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REVIEW the asessment to avoid missing or forgetting any information.
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What should you do in closure of the assessment?
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Summarize your findings and concerns with the client & validate their most imporant problem.
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What is the final step after your interview?
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DOCUMENTATION of findings into the client's records LEGIBLY & CONCISELY according to agency's protocol
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What are the scalene and sternomastoid muscles known as?
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ASSESSORY MUSCLES
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What is bronchophony?
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WHEN WORDS SUCH AS NINETY-NINE SOUND LOUDER & CLEARER THAN THEY USUALLY DO
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When a client says "ee" and it transmit as "ay," what is this known as?
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EGOPHONY
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Normal breathing sounds occurs at what rate?
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12 TO 20 TIMES PER MINUTE
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What is retraction?
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BACKWARD OR INWARD MOVEMENT OF AN ORGAN OR PART
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Why is lifespan considerations important?
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TO INDIVIDUALIZE THE ASSESSMENT TECHNIQUES TO GET INFO. FROM THE CLIENT
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What should assessment of the abdomen focus on?
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NORMAL EXCRETORY FUNCTION & SPECIFIC MANAGEMENT TO ASSIST NORMAL FUNCTION
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