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Assessment ch 20
Exam 2
19
Nursing
Undergraduate 3
03/18/2011

Additional Nursing Flashcards

 


 

Cards

Term

 

Veins

Definition
-transport blood to heart
-de-oxygenated except pulmonary
-wide lumen
-less muscle/elastic tissue
-valves
-edema
Term

 

arteries

Definition
-high pressure
-transport blood away from the heart
-oxygenated blood-except for pulmonary artery
-narrow lumen
-more muscle/elastic tissue
-no valves
-ischemia-decreased oxygen to tissue
--complete obstruction:tissue death
--partial obstruction: pain after exercise decreasing with rest
Term

 

Arteries: structure and function

Definition
temporal artery
carotid artery
arteries in the arm
-brachial
-ulnar
-radial
arteries in the leg
-femoral
-popliteal
-dorsalis pedis
-posterior tibial
Term

 

veins: structure and function

Definition
jugular veins
veins in the arm
-superficial veins return most blood
veins in the leg
-deep veins
--femoral
--popliteal
-superficial veins-used often for coronary bypass
--great saphenous
--small saphenous
perforators (connecting veins)
Term

 

Lymphatics: structure and function

Definition
-very slow-
-right lymphatic duct-empties into the right subclavian vein, it drains the right side of the head and neck, right arm, right side of thorax, right lung and pleura, right side of the heart, and right upper section of the liver
-thoracic duct- drains the rest of the body. it empties into the left subclavian vein

functions of the lymphatic system
-lymph nodes
--head/neck
--arm (epitrochlear/axillary)
--inguinal
-infection-location
-lower extremities
--hand
Term

 

immune-related organs

Definition
tonsils
-pharyngeal(adenoid)
-palatine
-lingual
lymph nodes
thymus gland
spleen
lymphoid tissue in intestines-peyer's patches
bone marrow
Term

 

Subjective data

health history questions

Definition
leg pain or cramps
-intermittent claudication is a cramp that decreases after rest, caused by decreased oxygen to area
-cramps and increased warmth in calf can be a sign of thrombosis -do not perform homan's sign
skin changes on arm or legs
swelling
lymph node enlargement
medications
exercise: bed rest, inactivity, plane ride
-blood pools in the veins and may create a clot
Term

 objective data

the physical exam

 

inspection

Definition
-skin-note any needle marks
-make sure to inspect bilaterally
-symmetry
-profile sign (to detect early clubbing)
-range of motion
fingers
hands
arms
shoulders
Term

 

palpatation-upper extremities

Definition
temperature-dorsal hand
capillary refill- less than 1-2 sec
radial pulse - bilaterally
ulnar pulse
brachial pulse
epitrochlear node
do not perform a modified allen's test
Term

 

inspection

 

lower extremities

Definition
skin
hair distribution
symmetry
range of motion
-toes, ankle, knees, hips
Term

 

palpatation

 

lower extremities

Definition
temperature
calf muscle
inguinal lymph nodes
femoral pulse
popliteal pulse
posterior tibial pulse
pretibial edema
-non-pitting edema usually lymphatic obstruction
-unilateral edema may be due to deep vein occlusion or lymphatic obstruction
Term

 

edema

Definition
bilateral when caused by a systemic problem such as heart failure or unilateral when to the result of a local obstruction or inflammation.
Term

 

Homan's sign

Definition
pain when flexing knee is positive Homan's sign, which occurs in about 35% of cases of deep vein thrombosis
Term

 

edema scale

Definition
1+ mild pitting-slight indentation, no perceptible swelling
2+ moderate pitting
3+deep pitting
4+ very deep pitting
Term

 

auscultation

Definition
stethoscope
-bell
-assess for bruit
-turbulent blood flow
-partial occlusion of artery
femoral
abdominal
-aortic
-iliac
-renal
Term

 

summary checklist: peripheral vascular exam

Definition
inspect arms for color, size, any lesions
palpate pulses:radial, brachial
check epitrochlear node
inspect legs for color, size, any lesions, trophic skin changes
palpate temperature of feet and legs
palpate inguinal nodes
palpate pulses: femoral, popliteal, posterior tibial, dorsalis pedis
Term

 

variations in arterial pulse

Definition
weak, thready pulse 1+
-hard to palpate, need to search for it, may fade in and out, easily obliterated by pressure
-associated with decreased cardiac output, peripheral arterial disease, aortic valve stenosis

full, bounding pulse 3+
-easily palpable, pounds under your fingertips
-hyperkinetic states-exercise, anxiety, fever), anemia, hyperthyroidism
Term
 health history questions
Definition
Leg pain or cramps: Any? Where?
Skin changes on arm or legs: Any? What color: redness, pallor, blueness, brown discolorations?
Swelling: Swelling in one or both legs? When did this swelling start?
Lymph node enlargement: Any “swollen glands” (lumps, kernels)? Where in body? How long have you had them?
Medications: What medications are you taking (e.g., oral contraceptives, hormone replacement)?
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