Term
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Definition
a heart rate less than 50 bmp
occurs in well-trained athlete whose heart muscles develop along with the skeletal muscles |
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Term
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Definition
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Term
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Definition
heart rate over 90 bpm
occurs with anxiety are increased exercise to match the body's demand for increased metabolism |
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Term
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Definition
Four qualites to consider are stroke volume,bradycardia,tachycardia, sinus arrhythmia
Gives rate and rhythm of the heartbeat, location data of the condition of the artery
Assess rate, rhythm, and force
30-second intervals-start at "zero"
If irregular count for full minute
A wek, thready pulse reflict decreased stroke volume(1+) hemorrhagic shock; A full bounding pulse denotes an increased stroke volume(3+) as with anxiety, exercise,and some abnormal conditions |
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Term
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Definition
In the adult at physical and mental rest, normal range at 5 beats per minute
Rate varies with age, more rapid in children and infants
Rate is more moderate during adult and older years
Rate varies with gender; after puberty, females have a slightly faster rate than males |
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Term
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Definition
| The heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and and slowing to normal with expiration. Inspiration momentarily causes a decrease stroke volume from the left side of the heart; to compensate, the heart rate increases |
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Term
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Definition
| the maximum pressure felt on arterial artery during left ventricle contraction, or systole |
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Term
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Definition
| elastic recall or resting pressure that the blood exerts constantly between each contraction |
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Term
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Definition
| the difference between systolic and diastolic pressures and reflects the stroke volume |
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Term
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Definition
| the pressure forcing blood into the tissues, averaged over the cardiac cycle |
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Term
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Definition
A drop in this systolic pressure more than 20 MM HG or orthostatic pulse increase of 20 BPM or more with a quick change to a standing position
These changes are due abrupt peripheral vasodilation without a compensatory increasing cardiac output. orthostatic changes also occur with prolonged bedrest,older age, hypovolemia and some drugs |
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Term
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Definition
| the aneroid gauge to measure blood pressure |
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Term
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Definition
| Fever, is caused by pyrogrns secreted by toxin bacteria during infection or from tissue breakdown such as that following myocardial infarction, trauma, surgery,or malignacy. Neurological disorders examples are cerebral vascular accident, cerebral endema, brain trauma, tumor or surgery also can rest the brains thermostat at a higher level resulting in heat production and conservation |
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Term
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Definition
| usually due to accidental prologue exposure to cold. I dot also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation,or gastrointestinal hemorrhage |
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Term
| tympanic membrane theromometer |
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Definition
| senses infrared emission of the tympanic membrane(eardrum) |
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Term
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Definition
| body parts will equally bilaterally are in relative proportion to each other |
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Term
| Techniques for palpataion |
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Definition
Finger tips
A grasping action of the fingers and thumb
The Dorsa(backs) backs of hands and fingers
Base of fingers(metacarpophalangeal joints) |
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Term
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Definition
| best for fine tactile discrimination, as of skin texture, sweeling, pulsation, and determining presence of lumps |
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Term
| A grasping action of the fingers and thumb |
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Definition
| To detect the position, shape, and consisticy of an organ or mass |
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Term
| The Dorsa(backs) backs of hands and fingers |
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Definition
| best for determining temperature beacuse the skin here is thinner than on the palms |
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Term
| Base of fingers(metacarpophalangeal joints) or ulnar surface of the hand |
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Definition
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Term
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Definition
Conscetrated on watching
Close, careful scrutiny of first the individual as a whole and then each body system
Begain the moment you first meet the person and develop a "general survey" |
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Term
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Definition
| Earpiece, Diaphragm, Bell, tubing |
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Term
| High pitched sounds on a stethoscope |
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Definition
Use diaphragm
Breath, Bowel, normal heart sounds
Press endpiece fimly on skin |
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Term
| Low pitch sounds on a stethoscope |
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Definition
Use Bell
Extra heart sounds or murmurs
Hold end piece lightly on skin |
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Term
| Techniques to build rapport when completing a physical exam |
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Definition
Be confident, considerate and unhurried
Start with nonthreating actions such as vitals and wieght
Provide privacy
Use good hygine in front of client
Encourage questions
Explain each step of the examination
Avoid distractions and concetrate on one step at a time
Provide breif teching
Summarize findings and thank the client |
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Term
| Correct positioning for aging adult for physical examination |
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Definition
Sitting on the examination table
If frail may need to be supine
Arrage sequnce to allow as few position changes as possible
Allow rest when needed |
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Term
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Definition
Age
Sex
Level of consciousness
Skincolor
Facial features |
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Term
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Definition
Stature
Nurtition
Symmetry
Posture
Position
Body build, conture |
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Term
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Definition
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Term
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Definition
Facial Expression
Mood and affect
Speech
Dress
Personal Hygiene |
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Term
| Route of emperature mesurements |
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Definition
Rectal
Oral
Tympanic membrane Therometer (TMT) |
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Term
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Definition
| - use only if other routes are not practical, persons in shock or cannot close mouth due to breathing or oxygen tubes wired manidibale or other facial dysfuntion |
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Term
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Definition
| not used beacuse of concerns of mercury pollution from medical waste incinerators |
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Term
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Definition
| is usually lower than other age groups(97.2) |
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Term
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Definition
Normal and accurate
(98.6) |
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Term
| Tympanic membrane Therometer (TMT) |
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Definition
Eardrum
Accurate measurement of core temperature
Uncouncious paientd, emergency department, recovery areas, labor and delivery |
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Term
| Factors that determine blood pressure |
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Definition
Cardiac Output
Perpheral vascular pressure
Volume of circulating blood
Viscoity
Elacticity of vessel walls |
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Term
Inaccurate cuff size:
Cuff too narrow for extrimity |
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Definition
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Term
Inaccurate cuff size:
Cuff wrap is too looses or uneven, or bladder ballons out of wrap |
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Definition
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Term
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Definition
| Blood pressure is taken supine, sitting, and standing. |
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Term
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Definition
"Unpleasant sensory and emotional experience associated with actual or potiential tissue damage or described in terms of suce damage. it is always subjective."
A highly complex and subjective experience that originates from the central nurvous systen(CNS) or peripheral nervous system(PNS) |
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Term
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Definition
the periphery and central nervous system are functioning and intact.
It starts outside of the nervous system from actual or potential tissue damage
It can be divided into 4 phases: 1-transduction,2-transmission,3-perception,4-modulation
Examples include pulling hand away from fire, skinned knee, kidney stones, menstural cramps, venipuncture, arthritic joint pain
Predictable and time limited based on the extent of injury |
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Term
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Definition
Pain that implies an abnornal processing of pain message from an injury to the nerve fibers.
Most difficult to assess and treat.
Is precieve long after injury heals and
can start 2 or 3 years after intial injury.
Examples include diabetes, herpes, HIV?AIDS, sciatica, trigeminal neuraaalgia, phantom lib pain, chemotheropy. CNS lesions such as stroke multiple sclerosis and tumeur..
Cannot be identified by x-ray, cCAT scan or MRI. Elctromyography and nerve-conduction studies are needed. |
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Term
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Definition
Visceral pain
Deep somatic pain
Cutaneous pain
Referred pain |
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Term
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Definition
Pain that originates from the larger organs(kidney, stomach,intestine, gallbladder, pancrease)
Exmaples-ureteral colic, acute appendicitis, ulcer pain, cholecystis
Often presents vomiting, nausea, pallor, diaphoresis. |
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Term
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Definition
Comes from sources such as blood vessels, joints, muscules,bone injury
may result from pressure, truma, ischemia |
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Term
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Definition
Derived fron skin surfaces and subcutaneous tissue
Injury superficial with sharp, burning sensation |
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Term
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Definition
| Pain that is felt at a particular site but originates from another location |
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Term
Physiological changes from poorly managed pain:
Cardiac |
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Definition
Tachycardia
Elavated blood pressure
increased myocardial oxygen demand
Increased cardic output |
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Term
Physiological changes from poorly managed pain:
Pulmonary |
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Definition
Hypoventilaion
Hypoxia
Decreased cough
Atelectasis |
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Term
Physiological changes from poorly managed pain:
Gastrointestinal |
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Definition
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Term
Physiological changes from poorly managed pain:
Renal |
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Definition
Oligura
Unrinary retention |
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Term
Physiological changes from poorly managed pain:
Musculoskeletal |
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Definition
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Term
Physiological changes from poorly managed pain:
Central nervous system |
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Definition
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Term
Physiological changes from poorly managed pain:
Immune |
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Definition
Imparied cellular immunity
Impaired wound healing |
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Term
Physiological changes from poorly managed pain:
Poorly controles chronic pain |
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Definition
Depression
Isolation
Limited mobility an function
Confusion
Family distress
Diminished quality of life |
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Term
| Subjective data for assessing pain |
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Definition
Location
Duration
Quality
Intesity
Aggravating/ or reliving factors
Manner of expressing pain
Effect on ones life |
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Term
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Definition
Epidermis-outer highly differeniated
Dermis-Inner supportive |
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Term
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Definition
Basal cell layer-forms new cells(keratin, melanin)
Horny cell layer-Dead keratinized cells that are interwoven and closely packed
Avascular-nourished by blood vesseles in the dermis layer |
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Term
| Dermis-inner support layer |
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Definition
Consisting mostly of connective tissue or collagen
Nerves, sensory receptors, blood vessels, lymphatics
Hair follicals, sebaceous glands, sweat glands |
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Term
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Definition
Layers of fat cells
Stores fat for energy
Insulation for temperture control
Aids in protection by its soft cushining effect |
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Term
| How often is skin replaced |
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Definition
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Term
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Definition
Produce dilute saline solution called sweat
Sweat reduce body temperature
Mature by two months of age |
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Term
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Definition
Produce a thick milky secretion and open int hair follicles
Located maily in the Axille, anogential area, nipples, and navel
Become active during puberty
Secretion occurs with emotional and sexual stimulation
Bacterial flora resiging on skin surfave react with apocrine gland to produce musky body odor
Decrease in aging adult |
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Term
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Definition
Prompt a loss of self-esteem for many adults
Skin loses elasticity
Looks parchment thin, lax, dry, wrinkeled
Epidermis thins and flattens
Lost of elastin, collagen, subcutaneous fat
Reduction in muscle tone
Lost of collagen increases risk for shearing and tearing injuries
Decrease in sweat and sebacecous glads leaving dry skin |
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Term
| Decribe nursing assessment for dehydrated patient |
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Definition
Mucous membraneds are dry
lips look parched and cracked
With extreme disress, the skin is fissured,resembling cracks in a dry lake |
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Term
| Decribe nursing assessment for abnormal nail finding |
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Definition
Jagged, bitten to the quick or traumatized nail folds suggest nouvous picking habits
Chronically dirty nails suggest pood self-care or occupation that make itimpossible to keep nails clean
Clubbing occurs with congenital cyanotic heart disease, neoplastice and pulmanary disease
Pits, transvers grooves or lines may indicate nutrient deficiency or may accompany acute illiness that disturbs growth
Nails are thicked and riged ith arterial insufficiency
Spongy nail base accompany clubbing
Cyanosis or marked pallor
Brown linear streaks in lightskined peple are abnormal and may indicate melaoma
cyanotic nail bed or sluggish return: consider cardiovascular or respiratory dysfunction |
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Term
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Definition
Dry skin.
Common in aging person because of a decline in size number and output od sweat and sebaceous.
skin itches and looks flaky and loose |
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Term
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Definition
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Term
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Definition
Male pattern baldness
Genetic
Men and women
Hairline W shape
Turns gray because od dereases in melanocyte function |
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Term
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Definition
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Term
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Definition
| When the res-pink tones from the oxyegnatedhemoglobin in the blood is lost the skin takes on the color of connective tissue(collegen) |
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Term
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Definition
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Term
Primary headache:
Migraine |
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Definition
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Term
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Definition
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Term
| Assessment following enlarged thyroid |
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Definition
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Term
| Assessment following enlarged lymph |
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Definition
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Term
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Definition
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Term
| Abnormal thyroid gland finding |
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Definition
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Term
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Definition
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Term
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Definition
| Earache, Infection, Discharge, Hearing loss, Environmental noise, Tinnitus, Vertigo, Self-care behavior |
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Term
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Definition
Shape and Size, Skin Condition, Tenderness, External Auditory Meatus
Inpect and palpate the external ear
Inspect with otoscope
Test hearing hearing acuity
whisper voice test
tuning fork test
Robmerg test for balance |
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Term
| Assessment for TM with otoscope |
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Definition
NOTE SIZE OF AUDITORY MEATUS
HOLD OTOSCOPE UPSIDE DOWN |
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Term
| Function of Eustachian tube |
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Definition
PROTECTS THE INNER EAR BY REDUCING TH AMPLITUDE OF LOUD SOUNDS
3)ITS EUSTACHIAN TUBE ALLOWS EQUALIZATION OF AIR PRESSURE ON EACH SIDE OF TH TYMPANIC MEMBRANE SO THAT THE MEMBRANE DOES NOT RUPTURE |
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Term
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Definition
1)CONDUCTS SOUND VIBRATIONS FROM THE OUTER EAR TO THE CENTRAL HEARING APPARATUS IN THE INNER EAR
2)PROTECTS THE INNER EAR BY REDUCING TH AMPLITUDE OF LOUD SOUNDS
3)ITS EUSTACHIAN TUBE ALLOWS EQUALIZATION OF AIR PRESSURE ON EACH SIDE OF TH TYMPANIC MEMBRANE SO THAT THE MEMBRANE DOES NOT RUPTURE |
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Term
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Definition
EXTERNAL EAR OR PINNA
MOVEABLE CARTILAGE AND SKIN |
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Term
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Definition
| CONTAINS THE CENTRAL HEARING APPARATUS |
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Term
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Definition
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Term
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Definition
BONY PROMINENCE BEHIND THE LOBE
NOT PART OF THE EAR |
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Term
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Definition
RINGIN, CRACKLING, OR BUZZING IN THE EARS
ORIGINATES WITHIN THE PERSON
SEEMS LOUDER WITH ON COMPETITION FROM ENVIRONMENTAL NOISE |
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Term
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Definition
| Light head, swimming sensation, feelig of falling |
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Term
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Definition
| True rational spinning from neurological disease (labyrinth -vestibule apparatus, vestibule nuclei in brainstem) |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| Assessment for identifying sinus area |
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Definition
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Term
| Structures and landmarks of the neck |
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Definition
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Term
Names of lymph nodes of the neck and there location :
Preauricular |
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Definition
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Term
| 4 areas where lymph nodes can be accessed |
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Definition
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Term
| Assessment that would follow palpataion of an abnormal lymph node |
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Definition
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Term
Names of lymph nodes of the neck and there location :
Posterior auricular (mastoid) |
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Definition
| Superficial to the mastoid process |
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Term
Names of lymph nodes of the neck and there location :
Occipital |
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Definition
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Term
Names of lymph nodes of the neck and there location :
Submental |
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Definition
| Midline, behind the tip of the mandible |
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Term
Names of lymph nodes of the neck and there location :
Submandibular |
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Definition
| Halfway between the angle and the tip of the mandible |
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Term
Names of lymph nodes of the neck and there location :
Jugulodiagastric |
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Definition
| Under the angle of the mandible |
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Term
Names of lymph nodes of the neck and there location :
Superficial cervical |
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Definition
| Overlying the sternomastoid muscle |
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Term
Names of lymph nodes of the neck and there location :
Deep cervical |
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Definition
| Deep under the sternomastoid muscle |
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Term
Names of lymph nodes of the neck and there location :
Posterior cervical |
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Definition
| In the posterior triangle along the edge of the trapezoid muscle |
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Term
Names of lymph nodes of the neck and there location :
Supraclavicular |
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Definition
| Just above and behind the clavicle, at the sternomastoid muscle |
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Term
| AREA OF BODY WHERE LYMPH NODES ARE ACCESSIBLE |
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Definition
HEAD AND NECK
ARMS
AXILLAE
INGUINAL REGION |
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