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F - Exam 5
Chapters 29 and 30
102
Nursing
Undergraduate 1
02/12/2012

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Term
When to assess vital signs
Definition
-On admission
-Change in client’s health status
-Client reports s/s of chest pain, feeling hot or faint
-Pre/post surgery or procedure
-Pre/post med administration that affects CV system
-Pre/post nursing interventions
Term
Factors Affecting Body Temperature
Definition
-Age
-Diurnal Variations (circadian rhythms)
-Exercise
-Hormones
-Stress
-Environment
Term
Factors Affecting Pulse
Definition
-Age
-Gender
-Exercise
-Fever
-Meds
-Hypovolemia
-Stress
-Position Changes
-Pathology
Term
Factors Affecting Respirations
Definition
-Exercise
-Stress
-Environmental Temp
-Meds (albuterol)
Term
Factors Affecting B/P
Definition
-Age
-Exercise
-Stress
-Race
-Gender
-Meds
-Obesity
-Diurnal Variations
-Disease process
Term
Sites for Measuring Temps
Definition
-Oral
-Rectal
-Axillary
-Tympanic Membrane
-Skin/Temporal Artery
Term
Intermittent fever
Definition
temp alternates at regular intervals b/w periods of fever and periods of normal temp. (malaria)
Term
Remittent fever
Definition
wide range of temp fluctuations, more than 2 degrees, over a 24 hour period all of which are above normal (cold or flu)
Term
Relapsing fever
Definition
short febrile periods of a few days are interspersed with periods of 1-2 days of normal temps
Term
Constant fever
Definition
temp fluctuates minimally but always remains above normal (typhoid fever)
Term
Fever spike
Definition
temp that rises to fever level rapidly following a normal temp and then returns to normal after a few hours (bacterial blood infections)
Term
Heat exhaustion
Definition
result of excessive heat and dehydration. s/s paleness, dizziness, N/V, fainting and moderately increased temp (101-102)
Term
Heat stroke
Definition
exercising in hot weather. s/s warm flushed skin, often do not sweat, temp of 106 or higher.
Term
Pulse Sites
Definition
-Radial
-Temporal
-Carotid
-Apical
-Brachial
-Femoral
-Popliteal
-Posterior Tibial
-Dorsalis Pedis
Term
Characteristics of the Pulse
Definition
-Rate (bpm, tachy, brady)
-Rhythm (equality, dysrhtymias, arrhythmia)
-Volume (strength, bounding, absent)
-Arterial wall elasticity (expands or deformed)
-Presence/Absence of bilateral equality
Term
Characteristics of Respirations
Definition
-Rate (bpm, eupnea, bradypnea, tachypnea)
-Depth (normal, deep, shallow)
-Rhythm (regular/irregular)
-Quality (effort, sounds)
-Effectiveness ( uptake and transport of O2/ elimination of CO2)
Term
Purposes of Physical Examination
Definition
-Obtain baseline data
-Supplement, confirm or refute data from history
-Help establish nursing diagnosis and plans of care
-Evaluate physiologic outcomes and progress
-Make clinical judgments
-Identify areas of health promotion and disease prevention
Term
Methods Used in Physical Examination
Definition
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Term
Conduction Hearing Loss
Definition
result of interrupted transmission of sound waves through the outer & middle ear. Possible causes are tear in tympanic membrane or obstruction
Term
Sensorineural hearing loss
Definition
result of damage to inner ear, the auditory nerve or hearing center in the brain.
Term
Mixed hearing loss
Definition
A combination of conduction hearing loss and sensorineural hearing loss
Term
When assessing hearing with a tuning fork which should be longer? Air Conduction or Bone Conduction
Definition
Air Conduction
Term
Dorsal Recumbent
Definition
Laying on back, knees flexed, hips rotated
Term
Supine
Definition
Laying on back with legs extended
Term
Lithotomy
Definition
Laying on back with feet supported in stirrups (commonly used for gyno. exams)
Term
Sims
Definition
Laying on side with lower arm behind body and upper leg flexed
Term
Prone
Definition
Laying on stomach with head turned to the side
Term
Trendelenburg
Definition
Face up and foot of the bed raise; used to treat shock (/)
Term
Reverse Trendelenburg
Definition
Face up and head of the bed raised and foot of the bed lowered (\); used to treat GERD and hiatal hernia
Term
Macule
Definition
Flat, unelevated, change in color; freckle, (flat) moles [Primary Skin Lesion]
Term
Papule
Definition
Circumscribed (confined), solid, elevation of skin; warts, acne, pimples [Primary Skin Lesion]
Term
Plaque
Definition
Larger than 1cm; ex. psoriasis, rubeola [Primary Skin Lesion]
Term
Nodule
Definition
elevated solid hard mass; ex. melanoma, hemangioma [Primary Skin Lesion]
Term
Pustule
Definition
vesicle or bulla filled with puss [Primary Skin Lesion]
Term
Vesicle
Definition
Circumscribed (confined)round thin translucent mass filled with serous fluid; blister [Primary Skin Lesion]
Term
Cyst
Definition
1cm or larger elevated fluid filled mass [Primary Skin Lesion]
Term
Wheal
Definition
reddened localized collection of edema fluid; allergic reaction [Primary Skin Lesion]
Term
Atrophy
Definition
A translucent, dry, paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin. Ex. Striae, aged skin [Secondary Skin Lesion]
Term
Erosion
Definition
Wearing away of the superficial epidermis causing a moist, shallow depression. Because erosions do not extend into the dermis, they heal without scarring. Ex. Scratch marks, ruptured vesicles [Secondary Skin Lesion]
Term
Lichenification
Definition
Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing. Ex. Chronic dermatitis [Secondary Skin Lesion]
Term
Scales
Definition
Shedding flakes of greasy, keratinized skin tissue. Color may be white, gray, or silver. Texture may vary from fine to thick. Ex. Dandruff, Psoriasis, Dry Skin, and Eczema [Secondary Skin Lesion]
Term
Crust
Definition
Dry blood, serum, or pus left on the skin surface when vesicles or pustules burst. Can be red-brown, orange, or yellow. Large crusts that adhere to the skin surface are called scabs. Ex. Eczema, impetigo, herpes, or scabs following abrasion. [Secondary Skin Lesion]
Term
Ulcer
Definition
Deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. May bleed. May leave a scar. Ex. Pressure ulcers, stasis ulcers, chancres. [Secondary Skin Lesion]
Term
Fissure
Definition
Linear crack with sharp edges, extending into the dermis. Ex. Cracks at the corners of the mouth or in the hands, athlete's foot. [Secondary Skin Lesion]
Term
Scar
Definition
Flat, irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or purple; older scars may be silvery or white. Ex. Healed surgical wound or injury, healed acne. [Secondary Skin Lesion]
Term
Keloid
Definition
Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. Extends beyond the site of the original injury. Higher incidence in people of African descent. Ex. Keloid from ear piercing or surgery. [Secondary Skin Lesion]
Term
Excoriation
Definition
Linear erosion. Ex. Scratches, some chemical burns. [Secondary Skin Lesion]
Term
Why should you assess the temporal pulse?
Definition
When the radial pulse is not accessible.
Term
Why should you assess the carotid pulse?
Definition
For use during cardiac arrest/shock in adults and in order to determine circulation to the brain. *NEVER CHECK BILATERALLY AT THE SAME TIME*
Term
Why should you assess the apical pulse?
Definition
In infants & children up to 3 years, discrepancies with radial pulse,and when certain medications are prescribed (digoxin). **It is the most accurate.
Term
Why should you assess the brachial pulse?
Definition
When obtaining B/P, and for cardiac arrest in infants.
Term
Why should you assess the femoral pulse?
Definition
For cardiac arrest/shock; and to assess circulation in the leg.
Term
Why should you assess the popliteal pulse?
Definition
For circulation in the lower leg.
Term
Why should you assess the posterior tibial pulse?
Definition
For circulation in the foot.
Term
Why should you assess the Dorsalis Pedis (Pedal) pulse?
Definition
For circulation in the foot. *Easily obliterated*
Term
Lymph Nodes found in the Head and Neck (9)
Definition
- Occipital
- Postauricular
- Preauricular
- Submandibular
- Submental
- Tonsillar
- Posterior Cervical
- Deep Cervical
- Supraclavicular
Term
Normal Breathing Sounds
Definition
- Vesicular
- Brocho-Vesicular
- Bronchial
Term
Broncho-Vesicular
Definition
Moderate intensity, "blowing" sound, best heard b/w scapulae and lateral to the sternum in the 1st and 2nd intercostal spaces (normal breath sound)
Term
Bronchial
Definition
high pitched, "harsh" sound, heard best anterior over the trachea; not normally heard over lung tissue. (normal breath sound)
Term
Vesicular
Definition
soft intensity, "gentle sighing", best heard over base of lungs (normal breath sound)
Term
Adventitious Breath Sounds
Definition
-Crackles (rales)
-Gurgles (rhonchi)
-Friction Rub
-Wheeze
Term
Crackles (rales)
Definition
fine, short crackling sounds; high pitched; best heard on inspiration but can be heard on both; will not clear when coughing; most commonly heard in base of lungs (abnormal breath sound)
Term
Gurgles (rhonchi)
Definition
low pitched, coarse, gurgling louder sounds; best heard on expiration but can be heard on both; caused by air bassing through narrowed passages due to swelling & secretions; CAN clear after coughing (abnormal breath sound)
Term
Friction Rub
Definition
superficial grating sound heard during inspiration & expiration; not relieved by coughing; caused by rubbing together the pleural spaces, heard in lower anterior/lateral chest (abnormal breath sound)
Term
Wheeze
Definition
continuous, high pitched musical sound; best heard on expiration, not altered by coughing, heard all over the lung fields. (abnormal breath sound)
Term
S1
Definition
Occurs when the Atrioventricular valves close. These valves close when they have filled up. It is a dull low pitched sound "lub".(normal)
Term
S2
Definition
After the ventricles have emptied the blood into the aorta and pulmonary arteries, the semilunar valves close causing a "dub" sound. This is higher pitched and shorter in duration. (normal)
Term
What are the vascular areas of the abdomen?
Definition
-Aorta
-Renal Artery
-Iliac Artery
-Femoral Artery
Term
What are the four abdominal quadrants?
Definition
-right upper quadrant
-left upper quadrant
-right lower quadrant
-left lower quadrant
Term
What are the nine abdominal regions?
Definition
-Right Hypochondriac
-Left Hypochondriac
-Epigastric
-Right Lumbar
-Left Lumbar
-Umbilical
-Right Inguinal
-Left Inguinal
-Hypogastric
Term
Four steps of examination of the abdomen. (In order)
Definition
1. Inspect 2. Auscultate 3. Percuss 4. Palpate
Term
Percussion of the Liver
Definition
Start 6 inches below the right lowest rib and percuss upwards until you hear a difference and mark continue until you hear another change and mark this is the first measurement. Start 3 inchest left of the midline of the abdomen and move right the first change in sound mark and at the final change in sound mark. This is the size of the liver. (left/right is according to the pt. perspective!)
Term
What should be heard when auscultating the abdomen?
Definition
Gurgling, dripping, and bruits.
Term
What should be felt when palpating the abdomen?
Definition
Minimal guarding and no hard nodules.
Term
How should the abdomen appear?
Definition
Symmetrical, "normal" skin, Inverted navel (umbilicus), regular contour (no bulging). *pulsations and peristaltic waves may be present*
Term
At the start of a Neurologic Exam what questions should you ask!
Definition
-Name
-Where they are
-What is the date/president
-Assess Memory
-Assess Level of Consciousness
Term
Glascow Coma Scale
Definition
Used to assess the level of consciousness of someone. The highest score possible is 15 (meaning pt. is alert and completely oriented.) A comatose client scores 7 or less. Assesses eye response, motor response, and verbal response.
Term
Cranial Nerve 1 - Olfactory
Definition
Identify smells w/eyes closed
Function: Smell
Term
Cranial Nerve 2 - Optic
Definition
Check visual fields, Snellen chart.
Function: Vision and Visual fields
Term
Cranial Nerve 3 - Oculomotor
Definition
Assess 6 ocular movements and pupil reaction
Term
Cranial Nerve 4 - Trochlear
Definition
Assess 6 ocular movements
Term
Cranial Nerve 5 - Trigeminal
Definition
Close eys and gently touch cotton over forehead, cheeks, and jawline; ask client to clench teeth
Term
Cranial Nerve 6 - Abducens
Definition
Assess directions of gaze
Term
Cranial Nerve 7 - Facial
Definition
Ask client to smile, raise eyebrows, frown, puff cheeks, and close eyes tightly
Term
Cranial Nerve 8 - Auditory
Definition
Romberg test, whisper test, tuning fork
Term
Cranial Nerve 9 - Glossopharyngeal
Definition
Move tongue up & down & side to side
Term
Cranial Nerve 10 - Vagus
Definition
Check pt. speech for hoarseness.
Term
Cranial Nerve 11 - Accessory
Definition
Shrug shoulders against resistance; turn head side to side with resistance.
Term
Cranial Nerve 12 - Hypoglossal
Definition
Protrude tongue and move it side to side.
Term
Where are the reflex locations?
Definition
Bicep, Brachioradialis, Triceps, Patellar, Achilles, Plantar (Babinski)
Term
What do you look for in a musculoskeletal assessment?
Definition
Size, symmetry, color, tenderness, edema, nodules, crepitus, and range of motion.
Term
Subjective Data
Definition
What is told to you by the client.This data is considered to be QUALITATIVE.
Term
Objective Data
Definition
What you discover during your assessment. Things like vital signs, auscultations, and palpation.
Term
4 Therapeutic Communication Techniques
Definition
- Active Listening
- Open-ended Questions
- Clarifying
- Summarizing
Term
What order should you use to examine everywhere EXCEPT the abdomen?
Definition
- Inspect
- Palpate
- Percuss
- Auscultate
Term
What order should you use when examining the abdomen only?
Definition
- Inspect
- Auscultate
- Percuss
- Palpate
Term
What is the diaphragm of the stethoscope used for?
Definition
Listening to high-pitched sounds (normal heart sounds, bowel sounds, and breath sounds)
Term
What is the bell of the stethoscope used for?
Definition
Listen to low-pitched sounds (abnormal heart sounds, bruits)
Term
Where would you expect to hear tympany?
Definition
Gastric bubble.
Term
Where would you expect to hear resonance?
Definition
Lungs.
Term
Where would you expect to hear a dull sound?
Definition
Over the liver.
Term
Where would you expect to hear a flat sound?
Definition
Over muscles.
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