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190 Cards in this Set

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(def)

an abnormal accumulation of fluid in the interstitial spaces of tissues
edema
Edema is always _________.
abnormal
Edema may be caused how?
- damage to an area of the body and the inflammatory response
- low albumin in the blood can cause plasma to seep into interstitial spaces
- any problem with a body system that regulates fluid (ex. cardiac, renal)
- impairment of venous return which overrides the capacity of the veins (ex. pregnancy)
- malnutrition
What is more likely to happen to edemic skin? What implication does this have on the nurse?
Skin is more likely to tear/breakdown; you must immediately start care to protect the skin
A client is suffering from edema in her feet. You push on the skin and it leaves an indentation. What is this referred to as?
pitting edema
True/False:

Pitting Edema is more severe than edema that does not pit.
False- This does not indicate severity of the edema. However, the nurse must document whether the area afflicted with edema pits or not.
If edema forms around the eyes, it is called what?
periorbital edema
If edema is located in the brain, it is called what?
cerebral edema
Edema in the pericardial sac is called what?
pericardial effusion
Edema in the intrapleural space is called what?
pleural effusion
Edema in the abdominal cavity is called what?
ascites
Generalized Edema (all over) is called what?
anasarca
Edema is affected by gravity and therefore is commonly seen in what areas?
Dependent areas
What dependent area in an active person would likely be affected by edema? How about a client on bedrest?
Active persons would likely suffer in feet and legs.

Bedrest persons would likely suffer in the sacral/dorsal regions of the body.
A client is being treated for liver disease. You suspect ascites. What method would you use to assess this client for changes?
abdominal girth measurements (done at the umbilical level) AND daily weight measurements
A nurse is caring for a client with ascites as a secondary symptom. She writes an independent order - Semi-Fowler's Position or higher at all times. Why do you think she wrote this order?
to reduce pressure on the diaphragm and ease breathing
(def)

any abnormal area of the skin (wound, cyst, rash, boil, pustule, tumor, etc.)
lesion
(def)

an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn.
excoriation
What is the procedure for assessing lesions of the skin?
- assess for location, size, shape, color, texture, raised or flat, mobility, drainage, tenderness, etc.
What guidelines do we use when reporting lesions? Briefly describe each guideline.
American Dermatology Association Guidelines

Report: A, B, C, & D

A= Asymmetry
B= Border Irregularity
C= Change in color or elevation
D= diameter >6mm
True/False:

You should call the doctor immediately if you find an abnormal skin lesion.
False - document and let the doctor know during his next shift.
What are some normal skin lesions that may be seen in an older adult?
- skin tags
- senile keratosis (thickening)
- cherry angiomas
- atrophic warts
True/False:

When examining hair, you should focus solely on the hair found on the head.
False- You should examine all hair (eyebrows, underarm, pubic, etc.)
What determines the color of your hair?
melanin
Describe the normal attributes of hair.
- straight/curly
- fine/course
- shiny and resilient
- should not come out in clumps >5 strands when gently tugged
Normal male or female pattern of baldness is _________.
hereditary
On average, how many strands of hair do you lose per day?
100
Hair is a good indicator of nutritional health, especially the body's _______ status.
protein
(def)

a partial or complete lack of hair resulting from normal aging, an endocrine disorder, a drug reaction, an anticancer medication, or a skin disease.
alopecia
Describe abnormal attributes for hair.
- brittle
- listless
- dull
- above normal hair loss
What are some causes of abnormal hair loss?
- serious infections
- chronic illness
- loss of hair on lower extremities may be caused by poor perfusion
What are normal attributes for hair in the elderly?
- thinning
- graying
- decreased in legs, axillae, pubic areas
- hormonal shifts may cause more hair on ears, eyebrows of males and face of females
What is the procedure for inspecting the head/scalp of an adult?
inspect skull for shape and size, palpate for lesions using a rotating motion with the fingertips
What is the procedure for inspecting hair?
- inspect for even distribution, thickness
- palpate for texture, oiliness
- check for infestations
- gently tug on hair for hair loss
- observe hair over entire body
Describe the normal skull and scalp.
- normocephalic
- symmetrical
- scalp = shiny, intact, no lesions
(def)

a pathologic condition characterized by an abnormal accumulation of CSF within the cranial vault and subsequent dilation of the ventricles
hydrocephalus
(def)

abnormal growth of the hands, feet, and face, caused by overproduction of growth hormone by the pituitary gland.
acromegaly
Describe abnormal features you should look for when inspecting head/scalp.
- hydrocephalus
- acromegaly
- scalp lacerations, lesions, indications of trauma
What nursing implications must you consider in relation to the head/scalp region?
- shearing force
- prolonged pressure is client is on bed rest
What is the procedure for inspecting the face?
- inspect facial features for symmetry.
- ask client to raise eyebrows, puff cheeks, smile
Describe normal findings when inspecting the face.
- symmetrical features
- tops of ears should align with the outer canthus of the eyes
- nose is midline
Describe abnormal findings you should look for when examining the face.
- facial drooping
- asymmetry
- (specific disorder cues such as CVA, Bells Palsy, Parkinson's)
A defect in CN VII may be indicative of what 2 disorders?
- Bells Palsy
- CVA
A blank stare with little expression combined with raised eyebrows may indicate what disorder?
Parkinson's
What should you specifically check when examining a patient's eyes?
- visual acuity
- eyelids
- sclera
- conjunctiva
- cornea/lens
- pupils
What cranial nerve is responsible for sight?
CN II (Optic Nerve)
(def)

the ability to see
visual acuity
What is the procedure for checking visual acuity?
- hold 2 or 3 fingers up (about a foot away) and ask client to identify
- identify a common object (ex. a pen, a watch)
Describe normal visual acuity.
able to identify common object at 1-20 feet
What abnormalities may you find when testing visual acuity?
- myopia
- hyperopia
(def)

nearsightedness
myopia
(def)

farsightedness
hyperopia
What are some changes in visual acuity you may see in older adults.
- reduced adaptation to darkness
- sensitivity to glare
- presbyopia
(def)

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.
presbyopia
At what age does presbyopia typically begin?
middle age >45
What is the procedure for examining eyelids?
- observe position of upper lids in relation to upper borders of the iris
- notice frequency of blinking
Describe normal eyelids.
- symmetrical
- upper lids cover upper portion of the iris
- when closed, lids cover cornea
(def)

drooping of the eyelid
ptosis
What nerve controls the eyelid muscles?
CN III (oculomotor)
Ptosis may be indicative of what 3 serious neurological disorders?
- CVA
- MS
- MG (myasthenia gravis)
What changes may you notice in the older adult when examining eyelids?
mild bilateral ptosis from loss of skin elasticity
What CN controls the pupil?
CN III (oculomotor)
What terms should be used to indicate a specific area within the eye? (ex. a scratch, red area)
nasal/temporal
You should inspect the pupils for what 4 things?
color, symmetry, size and shape
What is the procedure for examining the sclera?
- ask client to look up, down, side to side
- nurse may open lids if client is unable to do so
Describe normal sclera.
- moist
- light skin clients = color is off white
- dark skin clients = color is tan with brown areas of melanin
What abnormalities might you find when examining the sclera?
- uniformly yellow (jaundice)
- bluish (thinning of skin/hypoxia)
What is the normal procedure for examining the conjunctiva?
- retract lower lid with nurse's opposite thumb; inspect as client is asked to look upward
Describe the normal conjunctiva.
Pink, moist with some small blood vessels visable
Describe abnormal conjunctiva.
- pale (anemia)
- conjunctivitis (reddened with or without purulent discharge)
(def)

an opaque ring, gray to white in color, that surrounds the periphery of the cornea; caused by lipid deposits; harmless. Occurs primarily in older adults.
arcus senilis
Describe normal cornea/lens.
Moist, shiny without discharge, cloudiness or irregularities
Describe abnormal cornea/lens.
Ulcers
Dryness
Lacerations (from trauma or contact lenses)
Describe normal findings when examining pupils.
- PERRLA (pupils equal, round, react to light and accommodation)
- Size 2-7 mm
- brisk response to light
- bilateral direct and consensual responses
- mydriasis
- miosis
(def)

dilation of the pupil for distance
mydriasis
(def)

pinpoint constriction of the pupil for close sight
miosis
Describe abnormalities you may see when observing pupils.
- pinpoint or dilated pupils
Pinpoint sized pupils may indicate what?
- narcotic opioid use
- some glaucoma medications
Dilated pupils may indicate what?
- sympathetic stimulation
- blocking of parasympthetic system to dry oral secretions (ex. the drug Atropine)
- Increased Intracrainal pressure
If a client's eyes are dilated, what is your next step in the examination?
Ask the client if they have had surgery (ex. cataract or glaucoma surgery)
(def)

contraction of the pupil of one eye when the other retina is stimulated; it is a normal reflex and a test to evaluate the second and third cranial nerves
consensual response (reaction)
(def)

an adjustment of the eyes for near vision, consisting of pupillary constriction, convergence of the eyes, and increased convexity of the lens
accommodation reflex
Describe the test used for accommodation reflex.
Hold a pen/finger directly in front of client. Ask them to focus on it, followed by focusing on the wall behind the object.
What do you write on the chart if the client passes all pupil examinations?
PERRLA
Describe the normal test for inspecting the ear.
- inspect for position of the ear (superior border at the level of the canthus)
- lift pinna upward to open ear canal, inspect for cerumen/drainage
- occlude one ear and whisper a "simple" word into client's other ear. Ask them to repeat it.
Describe normal ear findings.
- intact if hears whispered word
- yellow/brown cerumen in external ear canals
Describe abnormal ear findings.
- presbycusis
- clear watery drainage could be CSF (report STAT)
(Def)

hearing deficit
Presbycusis
Green or Gold cerumen may indicate what?
infection
What does the abbreviation HOH mean?
Hard of Hearing
Describe the normal procedure for inspecting the nose.
- inspect position
- lift tip and inspect for moisture, drainage, equality of airflow
Describe normal findings for the nose.
- midline
- nares patent, without discharge
- mucosa pink, moist
Describe abnormal findings of the nose.
- deviated septum (can obstruct airflow)
- edema
- excoriation (injury to the body)
What changes can you expect to not in the older adult regarding the nose?
- decreased sense of smell
What structures do you examine when looking at the mouth?
- lips
- mucus membranes
- tongue
- uvula
- gums
- teeth
Describe the procedure for inspecting the mouth.
- inspect lips for symmetry, color, moisture.
- ask client to protrude the tongue and move it left and right.
- using a penlight and tongue blade, inspect all mm (tongue, hard palate, buccal mucosa, structures of the oropharynx in sweeping order, inspect teeth
Describe normal findings when inspecting the mouth.
- oral mucosa pink and moist
- tongue and uvula midline
- 32 teeth
- dark skinned clients may have brown patches of melanin on mm
(def)

no teeth
Edentulous
(def)

cavities
caries
What abnormalities might you find when inspecting the mouth?
- pallor
- cyanois
- dry
- tongue deviates left or right
- Candidiasis or thrush
- Endentulous
- Caries
- Gingival hyperplasia
(def)

white coating on the tongue
Candidiasis (thrush)
(def)

large, red gums
Gingival hyperplasia
What effect might you see on the gums of a client who is taking Dilantin - an anticonvulsant medication?
Gingival hyperplasia
What changes might you see in the mouth of the elderly?
- decreased sense of taste
- dry mm
- may have lost teeth
Describe the procedure for examining the neck.
- Visually inspect for symmetry, position of head and trachea.
- Apply resistance- ask client to move head left, right, up and down.
- Ask client to touch ear to shoulder
- Palpate trachea
- Ask client to tilt head to one side and palpate carotid pulse for rhythm and volume (avoid excessive pressure) - Repeat on other side and mentally compare
Describe normal findings when examining the neck.
- FROM (full range of motion)
- trachea midline
- carotid pulses equal, regular, strong
Describe abnormalities you may find when examining the neck.
- Limited ROM
- Trachea deviated
- Carotid pulses unequal, weak, irreg.
What might a deviated trachea indicate?
collapsed lung
What changes might you see in the elderly when examining the neck?
- sagging of skin
- weakened neck muscles
- limited ROM
Describe the procedure for examining breasts.
- inspect for symmetry, discharge, and dimples. Ask about pain.
True/False:

You can bypass the breast examination in male clients.
FALSE- breast cancer is found in male clients as well as female clients. You should NEVER bypass this part of the physical.
Describe normal findings for breasts.
symmetrical; without dimpling or discharge; non-tender
Describe abnormal findings for breasts.
asymmetrical; dimpling or discharge; palpable mass
Describe the procedure for examining the ANTERIOR thorax.
- Inspect for symmetry of the clavicles/ribs.
- Observe breathing pattern, rate, rhythm.
- Observe effort used to breath (note if accessory muscles are used)
- Observe is excursion/expansion of both sides of the thorax is equal
- Inspect for intercostal retractions or bulging
What is the normal ratio of transverse diameter to anterior-posterior diameter of the thorax?
2:1
What term is used to describe a thorax where the transverse diameter and anterior-posterior diameter is equal or the ant-post is greater than the transverse?
barrel chest
What is the cause of Barrel Chest?
air-trapping (as seen in COPD)
Describe the procedure for examining the posterior thorax?
- inspect for symmetry
- inspect for spinal alignment (straigtness)
- inspect for equality of excursion
- inspect skin integrity
- check for sacral edema
Describe normal findings for the thorax.
- symmetrical clavicles/ribs
- costal angle equal to or greater than 90 degrees
- Equal expansion (anterior and posterior)
- Eupnea
- Transverse greater than AP diameter
- spine midline/straight
- skin intact with no redness or edema
Describe abnormal findings for the thorax.
- asymmetrical
- unequal expansion
- paradoxical movement
- use of accessory muscles to breath
- labored breath
- intercostal retractions or bluging
- Barrel Chest
What might you expect to see when examining the thorax of an older adult?
- muscle atrophy and chest rigidity
- barreling due to decreased expansion
What are you analyzing when you examine lung sounds?
- equality (from side to side)
- characteristics of the lung sounds
The size of the airway determines the lung sounds. Therefore, the larger the airway diameter, the _______ and ________ the sound should be.
louder and harsher
What 3 breath sounds do we examine?
- Bronchial (tubular)
- Bronchovesicular
- Vesicular (Periphery)
Which side of the stethoscope do you use to analyze lung sounds?
diaphragm
How long should you analyze each lung sound?
at least one full cycle at each location
Describe the procedure for analyzing anterior lung sounds.
- Auscultate Bronchial
- Next auscultate bronchovesicular
- Next auscultate the vesicular

*Ask client to take deep, slow breaths*
Describe in detail the procedure for evaluating bronchial sounds anteriorly.
Assess left an right region over the trachea
Describe in detail the procedure for evaluating bronchovesicular breath sounds anteriorly.
- Listen at the sternal borders between 1-2 ICS
Describe in detail the procedure for evaluating (periphery) vesicular breath sounds anteriorly.
- Listen at supraclavicular spaces (apex)
- Listen to the mid-fields (midclavicular, anterior axillary, and mid-axillary lines
- Listen to the bases (midclavicular, anterior axillary, and mid-axillary lines)
Describe in detail the procedure for examining bronchovesicular breath sounds posteriorly.
- listen between the scapulae
Describe in detail the procedure for examining the periphery (vesicular) breath sounds posteriorly.
- listen at suprascapular areas
- listen to mid-field at the mid-scapular and posterior axillary lines
- listen to bases at the mid-scapular and posterior axillary lines
Describe normal findings for bronchial (tubular) sounds.
- harsh, loud
- Inspiration should be shorter than expiration
Describe normal findings for bronchovesicular sounds.
- inspiration equal to expiration
Describe normal findings for vesicular (peripheral) sounds.
- inspiration should be greater than expiration
- very quiet
What are some abnormal findings regarding breath sounds.
- unequal sounds
- adventitious sounds
- crackles
- wheezes
- rhonchi
- stridor
(def)

the incorrect sound is heard in a location
adventitious sounds
(def)

partial or complete collapse of a lung
atelectasis
What lung sound may be heard when atelectasis or fluid in the alveoli sacs is present?
crackle
What lung sound may be produced due to narrowed bronchial airways.
Wheezes
What lung sound sounds like snoring and may indicate sputum in the bronchi?
Rhonchi
What lung sound resembles crowing and may indicate an obstruction in the trachea or larynx?
Stridor
What does FBAO stand for?
Foreign Body Airway Obstruction
What are 3 disorders that may present "crackle" lung sounds as a symptom.
- Pneumonia
- PE (Pulmonary Edema)
- CHF (Congestive Heart Failure)
What are 2 disorders that may present "wheezing" lung sounds as a symptom.
- Asthma
- Bronchitis
What are 4 disorders that may present "stridor" as a symptom.
- FBAO
- Anaphylactic or allergic reaction
- croup
- tumor
What sound is produced by the heart as the AV valves (mitral and tricuspid) close?
S1
What heart sound represents systole (or the ejection phase)?
S1
What heart sound creates the peripheral pulses?
S1
What heart sound is produced by the closure of the semi-lunar valves (aortic, pulmonic)?
S2
What heart sound represents diastole (filling phase)?
S2
Describe the procedure for examining the heart/heart sounds.
- inspect precordium for lifts/heaves and pulsations
- identify angle of louis, then use both bell and diaphragm to listen at the 5LICS-MCL.
- note whether rhythm is regular or irregular
- while listening, palpate radial pulse (notice relationship with heart sounds)
- obtain apical pulse by counting for 60 seconds
What does PMI stand for?
Point of maximum impulse
Normally, the only palpable and visible pulse of the heart may be seen at the _____ area if the left ventricle pulsates against a thin chest wall.
apical
What is the normal location of an apical pulse?
5LICS, MCL
What is a normal AP-rate?
60-100/min
Describe normal heart sound findings.
AP rate 60-100
S-1, S-2 regular and strong
PMI @ 5LICS-SCL
What are examples of abnormal heart sound findings?
- displaced PMI
- irregular rhythm
- abnormal sounds
A displaced PMI may indicate what 2 disorders?
- cardiomegaly (enlarged heart)
- heart failure
What are some changes you may see in the elderly regarding the heart?
- cardiac muscle decreases in size
- compliance decreases (due to valve and left ventricle stiffness)
- cardiac output decreases by 35% by age of 70
What is the normal shape/contour of the abdomen?
rounded or flat
What is the order for examining the abdomen (3)?
- visually inspect
- auscultate
- palpate
How do you divide the abdomen?
Use the umbilicus as a midpoint and divide the abdomen into RLQ, RUQ, LLQ, and LUQ
When assessing bowel sounds, what is the normal timing between peristalsis sounds?
5-20 seconds
If bowel sounds occur faster than 5 seconds apart, what are they termed? What if they occur slower than 20 seconds apart?
faster than 5 = hyperactive bowel sounds

slower than 20 = hypoactive bowel sounds
Bowel sounds that fall within the range of 5-20 seconds are termed what?
normoactive bowel sounds
Describe the procedure for examining the abdomen.
- Inspect, auscultate, and palpate IN THAT ORDER
- Inspect for shape, contour, symmetry, scars, bruises, pulsations, etc.
- Auscultate each quadrant for bowel sounds
- Palpate each quadrant for tenderness, masses, etc.
Describe normal findings when examining the abdomen.
- round or flat contour
- normoactive BS x 4
- soft, non-tender
- Suprapubic area flat
What abnormalities might you find when examining the abdomen?
- concave or sunken
- distended (large/firm)
- hyperactive or hypoactive bowel sounds
- Absent bowel sounds after listening for 3-5 minutes
- Tenderness/pain
- Guarding
- Scars/incisions
- Audible pulse
A concaved abdomen might indicated what?
malnourishment
A distended abdomen might indicate what?
fluid in the abdominal cavity
An audible pulse (bruit) while examining the abdomen might indicate what?
- aneurysm - life-threatening weakness in a blood vessel
What is the purpose of auscultating bowel sounds of a patient who is just returning from surgery?
- to determine that the anesthesia is leaving the body system (the return of bowel sounds indicates anesthesia is wearing off)
Do narcotics increase or decrease peristalsis?
decrease
Describe the procedure for examining upper/lower extremities.
- inspect for muscle development, tone, symmetry, skin integrity
- assess for musculoskeletal strength and equality by asking the client to squeeze the nurses fingers
- test ROM
- Assess for perfusion (skin color, temperature, pulses, capillary refill, movement, and sensation)
- Inspect nail beds for color
- capillary refill test
- access for clubbing
- Homen's test for lower extremities only
Clubbing is caused by what?
Long term respiratory disorders
How do you examine a client for clubbing? What is the normal angle?
Place nails of 2 opposing fingers together to identify if angle is greater than 160 degress (normal)
Describe the capillary refill test. What is considered normal.
Depress and blanch the nail bed for 5 seconds - release; color should return in less than 3 seconds (normal)
What are normal findings for upper/lower extremities?
- symmetrical muscle development and strength
- smooth, firm tone
- FROM
- Bilateral, DP/PT & radial pulses +2
- nail beds pink
- capillary refill less than 3 seconds
- no clubbing
- bilateral neg. Homan's signs
Why should you not use the large toe to assess capillary refill?
because of the high incidence of ingrown toenails - could be painful for the client
Describe the Homan's test.
-lift one foot off the bed by placing your hand under the ankle
- dorsiflex the foot
- inquire about calf pain
- if there is pain, repeat once to confirm
- if confirmed, assess the leg for signs of inflammation (redness, warmth, edema, tenderness)
- repeat on other extremity
A client is in the hospital to be treated for deep vein thrombosis. What specific test would you exclude from the PE? Why?
exclude Homan's test - you could dislodge the clot
What abnormalities might you find when examining the lower extremities?
- decreased muscle size/poor tone
- limited ROM
- Pulse abnormalities, irregularities in amplitude/rhythm
- Nail beds pale
- Cap. refill takes more than 3 secs.
- Clubbing (Chronic hypoxia)
- Positive Homan's sign
- Involuntary movements (tics, spasms, rigidity)
- Paresthesia (numbness, tingling)
(def)

an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves.
paresthesia
What changes might you expect to see when examining the extremities of an older client?
- decreased muscle mass, tone, and strength (Should be symmetrical)
- decreased ROM
A Glasgow score of less than 6 indicates what?
coma
What 3 things does the Glasgow Coma Scale analyze?
- Eye opening (up to 4 pts)
- Motor Response (up to 6 pts)
- Verbal Response (up to 5 pts)
What is the maximum score (and normal result) for the Glasgow Coma Scale?
15
What is consider an abnormal score on the Glasgow Coma Scale?
anything lower than 15
What change might you expect to see when analyzing the mental status of an older adult?
decreased ability to respond to multiple stimuli