Term
| When to assess vital signs |
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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 |
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Term
| Factors Affecting Body Temperature |
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Definition
-Age
-Diurnal Variations (circadian rhythms)
-Exercise
-Hormones
-Stress
-Environment |
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Term
|
Definition
-Age
-Gender
-Exercise
-Fever
-Meds
-Hypovolemia
-Stress
-Position Changes
-Pathology |
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Term
| Factors Affecting Respirations |
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Definition
-Exercise
-Stress
-Environmental Temp
-Meds (albuterol) |
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Term
|
Definition
-Age
-Exercise
-Stress
-Race
-Gender
-Meds
-Obesity
-Diurnal Variations
-Disease process |
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Term
| Sites for Measuring Temps |
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Definition
-Oral
-Rectal
-Axillary
-Tympanic Membrane
-Skin/Temporal Artery |
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Term
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Definition
| temp alternates at regular intervals b/w periods of fever and periods of normal temp. (malaria) |
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Term
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Definition
| wide range of temp fluctuations, more than 2 degrees, over a 24 hour period all of which are above normal (cold or flu) |
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Term
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Definition
| short febrile periods of a few days are interspersed with periods of 1-2 days of normal temps |
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Term
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Definition
| temp fluctuates minimally but always remains above normal (typhoid fever) |
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Term
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Definition
| temp that rises to fever level rapidly following a normal temp and then returns to normal after a few hours (bacterial blood infections) |
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Term
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Definition
| result of excessive heat and dehydration. s/s paleness, dizziness, N/V, fainting and moderately increased temp (101-102) |
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Term
|
Definition
| exercising in hot weather. s/s warm flushed skin, often do not sweat, temp of 106 or higher. |
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Term
|
Definition
-Radial
-Temporal
-Carotid
-Apical
-Brachial
-Femoral
-Popliteal
-Posterior Tibial
-Dorsalis Pedis |
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Term
| Characteristics of the Pulse |
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Definition
-Rate (bpm, tachy, brady)
-Rhythm (equality, dysrhtymias, arrhythmia)
-Volume (strength, bounding, absent)
-Arterial wall elasticity (expands or deformed)
-Presence/Absence of bilateral equality |
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Term
| Characteristics of Respirations |
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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) |
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Term
| Purposes of Physical Examination |
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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 |
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Term
| Methods Used in Physical Examination |
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Definition
1. Inspection
2. Palpation
3. Percussion
4. Auscultation |
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Term
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Definition
| result of interrupted transmission of sound waves through the outer & middle ear. Possible causes are tear in tympanic membrane or obstruction |
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Term
| Sensorineural hearing loss |
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Definition
| result of damage to inner ear, the auditory nerve or hearing center in the brain. |
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Term
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Definition
| A combination of conduction hearing loss and sensorineural hearing loss |
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Term
| When assessing hearing with a tuning fork which should be longer? Air Conduction or Bone Conduction |
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Definition
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Term
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Definition
| Laying on back, knees flexed, hips rotated |
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Term
|
Definition
| Laying on back with legs extended |
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Term
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Definition
| Laying on back with feet supported in stirrups (commonly used for gyno. exams) |
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Term
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Definition
| Laying on side with lower arm behind body and upper leg flexed |
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Term
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Definition
| Laying on stomach with head turned to the side |
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Term
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Definition
| Face up and foot of the bed raise; used to treat shock (/) |
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Term
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Definition
| Face up and head of the bed raised and foot of the bed lowered (\); used to treat GERD and hiatal hernia |
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Term
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Definition
| Flat, unelevated, change in color; freckle, (flat) moles [Primary Skin Lesion] |
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Term
|
Definition
| Circumscribed (confined), solid, elevation of skin; warts, acne, pimples [Primary Skin Lesion] |
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Term
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Definition
| Larger than 1cm; ex. psoriasis, rubeola [Primary Skin Lesion] |
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Term
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Definition
| elevated solid hard mass; ex. melanoma, hemangioma [Primary Skin Lesion] |
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Term
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Definition
| vesicle or bulla filled with puss [Primary Skin Lesion] |
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Term
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Definition
| Circumscribed (confined)round thin translucent mass filled with serous fluid; blister [Primary Skin Lesion] |
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Term
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Definition
| 1cm or larger elevated fluid filled mass [Primary Skin Lesion] |
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Term
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Definition
| reddened localized collection of edema fluid; allergic reaction [Primary Skin Lesion] |
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Term
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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] |
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Term
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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] |
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Term
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Definition
| Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing. Ex. Chronic dermatitis [Secondary Skin Lesion] |
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Term
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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] |
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Term
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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] |
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Term
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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] |
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Term
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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] |
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Term
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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] |
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Term
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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] |
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Term
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Definition
| Linear erosion. Ex. Scratches, some chemical burns. [Secondary Skin Lesion] |
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Term
| Why should you assess the temporal pulse? |
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Definition
| When the radial pulse is not accessible. |
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Term
| Why should you assess the carotid pulse? |
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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* |
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Term
| Why should you assess the apical pulse? |
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Definition
| In infants & children up to 3 years, discrepancies with radial pulse,and when certain medications are prescribed (digoxin). **It is the most accurate. |
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Term
| Why should you assess the brachial pulse? |
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Definition
| When obtaining B/P, and for cardiac arrest in infants. |
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Term
| Why should you assess the femoral pulse? |
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Definition
| For cardiac arrest/shock; and to assess circulation in the leg. |
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Term
| Why should you assess the popliteal pulse? |
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Definition
| For circulation in the lower leg. |
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Term
| Why should you assess the posterior tibial pulse? |
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Definition
| For circulation in the foot. |
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Term
| Why should you assess the Dorsalis Pedis (Pedal) pulse? |
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Definition
| For circulation in the foot. *Easily obliterated* |
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Term
| Lymph Nodes found in the Head and Neck (9) |
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Definition
- Occipital
- Postauricular
- Preauricular
- Submandibular
- Submental
- Tonsillar
- Posterior Cervical
- Deep Cervical
- Supraclavicular |
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|
Term
|
Definition
- Vesicular
- Brocho-Vesicular
- Bronchial |
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Term
|
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) |
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Term
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Definition
| high pitched, "harsh" sound, heard best anterior over the trachea; not normally heard over lung tissue. (normal breath sound) |
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Term
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Definition
| soft intensity, "gentle sighing", best heard over base of lungs (normal breath sound) |
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Term
| Adventitious Breath Sounds |
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Definition
-Crackles (rales)
-Gurgles (rhonchi)
-Friction Rub
-Wheeze |
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Term
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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) |
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Term
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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) |
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Term
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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) |
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Term
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Definition
| continuous, high pitched musical sound; best heard on expiration, not altered by coughing, heard all over the lung fields. (abnormal breath sound) |
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Term
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Definition
| Occurs when the Atrioventricular valves close. These valves close when they have filled up. It is a dull low pitched sound "lub".(normal) |
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Term
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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) |
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Term
| What are the vascular areas of the abdomen? |
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Definition
-Aorta
-Renal Artery
-Iliac Artery
-Femoral Artery |
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Term
| What are the four abdominal quadrants? |
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Definition
-right upper quadrant
-left upper quadrant
-right lower quadrant
-left lower quadrant |
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Term
| What are the nine abdominal regions? |
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Definition
-Right Hypochondriac
-Left Hypochondriac
-Epigastric
-Right Lumbar
-Left Lumbar
-Umbilical
-Right Inguinal
-Left Inguinal
-Hypogastric |
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Term
| Four steps of examination of the abdomen. (In order) |
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Definition
| 1. Inspect 2. Auscultate 3. Percuss 4. Palpate |
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Term
|
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!) |
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Term
| What should be heard when auscultating the abdomen? |
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Definition
| Gurgling, dripping, and bruits. |
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Term
| What should be felt when palpating the abdomen? |
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Definition
| Minimal guarding and no hard nodules. |
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Term
| How should the abdomen appear? |
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Definition
| Symmetrical, "normal" skin, Inverted navel (umbilicus), regular contour (no bulging). *pulsations and peristaltic waves may be present* |
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Term
| At the start of a Neurologic Exam what questions should you ask! |
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Definition
-Name
-Where they are
-What is the date/president
-Assess Memory
-Assess Level of Consciousness |
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Term
|
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. |
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Term
| Cranial Nerve 1 - Olfactory |
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Definition
Identify smells w/eyes closed
Function: Smell |
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Term
|
Definition
Check visual fields, Snellen chart.
Function: Vision and Visual fields |
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Term
| Cranial Nerve 3 - Oculomotor |
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Definition
| Assess 6 ocular movements and pupil reaction |
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Term
| Cranial Nerve 4 - Trochlear |
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Definition
| Assess 6 ocular movements |
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Term
| Cranial Nerve 5 - Trigeminal |
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Definition
| Close eys and gently touch cotton over forehead, cheeks, and jawline; ask client to clench teeth |
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Term
| Cranial Nerve 6 - Abducens |
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Definition
| Assess directions of gaze |
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Term
|
Definition
| Ask client to smile, raise eyebrows, frown, puff cheeks, and close eyes tightly |
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Term
| Cranial Nerve 8 - Auditory |
|
Definition
| Romberg test, whisper test, tuning fork |
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Term
| Cranial Nerve 9 - Glossopharyngeal |
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Definition
| Move tongue up & down & side to side |
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Term
|
Definition
| Check pt. speech for hoarseness. |
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Term
| Cranial Nerve 11 - Accessory |
|
Definition
| Shrug shoulders against resistance; turn head side to side with resistance. |
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Term
| Cranial Nerve 12 - Hypoglossal |
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Definition
| Protrude tongue and move it side to side. |
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Term
| Where are the reflex locations? |
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Definition
| Bicep, Brachioradialis, Triceps, Patellar, Achilles, Plantar (Babinski) |
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Term
| What do you look for in a musculoskeletal assessment? |
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Definition
| Size, symmetry, color, tenderness, edema, nodules, crepitus, and range of motion. |
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Term
|
Definition
| What is told to you by the client.This data is considered to be QUALITATIVE. |
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Term
|
Definition
| What you discover during your assessment. Things like vital signs, auscultations, and palpation. |
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Term
| 4 Therapeutic Communication Techniques |
|
Definition
- Active Listening
- Open-ended Questions
- Clarifying
- Summarizing |
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Term
| What order should you use to examine everywhere EXCEPT the abdomen? |
|
Definition
- Inspect
- Palpate
- Percuss
- Auscultate |
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Term
| What order should you use when examining the abdomen only? |
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Definition
- Inspect
- Auscultate
- Percuss
- Palpate |
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Term
| What is the diaphragm of the stethoscope used for? |
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Definition
| Listening to high-pitched sounds (normal heart sounds, bowel sounds, and breath sounds) |
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Term
| What is the bell of the stethoscope used for? |
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Definition
| Listen to low-pitched sounds (abnormal heart sounds, bruits) |
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Term
| Where would you expect to hear tympany? |
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Definition
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Term
| Where would you expect to hear resonance? |
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Definition
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Term
| Where would you expect to hear a dull sound? |
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Definition
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Term
| Where would you expect to hear a flat sound? |
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Definition
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