Health assessment I Flashcards

Terms Definitions
Ecchymosis
Bruise
condylomata
warts
thrill
palpable vibration
OD
right eye
Pitting
Associated with psoriasis
 
Bowel obstruction sound
tinkling=fatal
anisocoria
unequal pupil size
apical impulse
5 ICS LMCL
Structure & Function:
Viscera
Internal Organs
Nose-Abnormal
Obstruction: absense of sniff
Rhinitis: swollen, bright red nasal mucosa, upper respiratory infection
Allergy: swollen, boggy, pale and grey mucosa, transver ridge, blue shadow under eye.
Sinunitis: discharge
 
RDA rec. for cho.
130gm/day
BNP
-B-type natriuretic peptide-substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops/worsens
bitot's spots
vitamin a deficiency
thrush
oral candidiasis of newborn
muscles of inspiration
diaphram and intercostals
Pons
Contains nuclei that control respiration.
Inspect the Abdomen:
Umbilicus abnormal findings
Enlarged and enverted umbilicus with ...
a Hernia
Nodule
Elevated, firm, circumscribed lesion; deeper in dermis than papule; 1-2 cm
 
Asthma
Airways are narrowed (reversible); Caused by inhaled pollen, irritants, micros, stress or exercise
Formal Operations
Adolescents (13-18)
Abstract thinking
Hypothetical situations
Can start to appreciate the perspective of others
Recognize injustices
Reciprocity & equal respect
Sensitive to hyprocrisy
spleen ans tomach are located
LUQ
Bronchitis
In this respiratory condition, Auscultation will be normal vesicular. Voice sounds will be normal, and there will be a chronic- prolonged expiration. Adventitious sounds will be crackles over deflated areas and possibly wheeze.
HDL
-lipoprotein found in blood-good cholesterol-lower risk of heart and blood vessel disease-men greater than 45mg/dl-woman greater than 55mg/dl
muscle
peaks in fetus and adolescence
physiologic splitting
S2splitting heard during inspiration
normal nail bed angle
160 degrees
this secretes lipid rich substance
sebaceous glands
bronchovesicular characterisitcs
medium pitched, medium intensity, muffled blowing quality, inspiration = expiration
pyloric stenosis
marked peristalsis and projective vomiting in infants (narrowed pyloric opening - food can't go from stomach to small intestine)
Dr. Davenport Nutrition Lecture:
Equal calories then energy needs =
No weight change
Developmental Care:
Pregnant Female
Signs of Pregnancy
Nausea, Vomiting
 
Missed Periods: Due to hormonal changes such as the production of human chorionic gonadotropin (HcG)
 
Acid Indigestion or heartburn (pyrosis) caused by esophageal reflux
 
GI Motility decreases = prolongs gastric emptying time = causes more water to be reabsorbed from the colon = leads to constipation --> constipation increases venous pressure in lower pelvis which may led to hemorrhoids
Alopecia
Hair Loss
 
Often occurs as a manifestation of many systemic diseases or treatment with radiation or antineoplastic agents
Tophi
Small, hard, whitish yellow, nontender nodules on helix; contain uric acid crystals
 
Sign of gout
R
region (location) and radiation. ex. tingling in left arm
Pneumonia
Inflammatory illness of the lung; Alveolar or parenchyma inflammation and abnormal fluid in the alveolar sac
What is vitamin C used for
A normal artery feels: spongy, springy, resilient and straight.
TB
In this respiratory condition, there will be normal or decreased vesicular breath sounds. Crackles over upper lobes common, persist following full expiration and cough.
pterygium
abnormal growth of conjunctiva that extends over the cornea from the limbus
retinitis pigmentosa
cell death in rod photrecptors
organ of corti
sensory organ of hearing
organs found in RLQ (2)
cecum, appendix
transverse Fx
completely through bone, straight across
the mediastinum
contains the heart, esophagus, blood vessels but does not contain the lungs
inflamaiton of the temperal artery is knows as what?
Temporalarteritis
S1 and S2
valve closure; can always hear
S4
muscle contraction (extra kick at end of distole)
Cerebellum
Located under the occipital lobe and connected to the mid brain, pons & medulla; processes input from other areas of the brain, spinal cord & sensory receptors to provide precise timing for coordinated, smooth movements of the skeletal muscular system.
Rickets
Sign of Vitamin D and Calcium deficiencies
 
Children: Disorders of cartilage growth, enlargement of epiphyseal growth plates
 
Adults: Osteomalacia (softening of the bones due to defective bone mineralization)
Epigastric Hernia
Small, Nodule at epigastrium in midline through the linea alba
 
One can feel rather then observe
 
Only palpable when standing
Linear Lesions
Lesions form a line
 
ex. poison ivy
 
Caries
Brown spots in crevices or between teeth
Bronchial Breath Sounds
High Pitch
Loud
Insp<Exp - 1:2
Over trachea
Abnormal: heard over peripheral lung fields
Reference Lines: Anterior
Midsternal Line and Midclavicular Line
Bronchophony
Ask person to say 99; Normal transition will be muffled and soft; if it is clear, it indiciates increased lung density
R: Region/Radiation
Where is it? Does it spread?
Examples of nodules
dermafibroma erythema nodosum, lipoma, melanoma, hemangioma, neurofibroma
T/F. In children, height is better correlated with BP than age.
True.
250-500mg/dl
what is the range for borderline triglycerides?
Platelet count
helps the blodd clot-smaller than RBC's and WBC's -Normal: 150,00-400,00 ml
stroke
sudden interruption of blood supply to brain
What chemicals are released at the time of pain?
Prostaglandins
S3
denotes CHF, normal if &lt;35 yo w/increased exercise; rapid ventricular filling
montgomery's glands
sebaceous glands in areola that secrete protective lipids during lactation
temp of testes
3 degrees lower than abdomen
caput medusa
spider veins in stomach; common w/cirrhosis
the kidneys produce
renin, erythopoietin, Vitamin D and are responsible for F&E balance
tricuspid valve auscultation site
apex of heart, 5 ICS
Knee Joint
Articulation of femur, tibia & patella (largest hinged joint)
Dr. Davenport Nutrition Lecture:
When do water needs increase?
Fever
Infections
Wounds (Open wounds loose lot of water)
GI Loss (Diarrhea, Vomiting, NG Sunction)
Respiratory disease (More energy to breathe, helps keep mucous liquified, Artificial Airway: Reduce ability of lungs to be provided with liquid by blocking the mucous membranes)
Dr. Davenport Nutrition Lecture:
Pellagra
Pigmented keratotic scaling lesions from Niacin Deficiency
Poor turgor is a sign of __________ which accompanies GI Disease
Dehydration
Atrophy
Thinning of the skin surface and loss of skin markings; skin appears translucent and paperlike
 
listening responses
attempts made by the nurse to accurately receive, process, and then respond to pt messages. they provide one way for the nurse to communicate empathy, concern, and attentiveness. in order to "listen" to what the pt says, the nurse must not only process words spoken by pt, but also understand the context of the pt's experience
Rinne Test
Compares air conduction of sound to bone conduction; should be AC>BC by 2:1
 
If BC>AC - conductive hearing loss
If AC>BC but less than 2:1 ration - sensorineural hearing loss
Respiration Patterns:
Cheyne-Stokes Respiration
Cycle in which respirations increase in rate and depth and then decrease; breathing periods last 30-45 seconds; Periods of apnea (20 seconds); Common cause is severe heart failure or renal failure, meningitis, drug overdose and increased intracranial pressure;
Occurs normally in infants and elderly while sleeping
Hypercapnia
Normal stimulus to breathe based on an increase in CO2 in the blood
Emergency Data base
rapid collection of data, often compiled concurrently with lifesaving measures
Examples of a macule
freckle, flat mole, petechiae, measles, scarlet fever
>160/>100
what are the blood pressure ranges for stage 2 hypertension?
20%
Obesity is > _____% of ideal body weight
120-139/80-89
what are the blood pressure ranges for prehypertension?
Total Cholesterol
-type of fat found in your blood-cholesterol is needed to maintain health of cells-done at any time without fastinggoal values: 75-169 mg/dl younger than 20 100-199 over age of 21
Turner's Syndrome
partial or complete absence of second X chromosome
What would you include in your exam of a depressed client?
· Posture· Movement· Dress· Hygiene· Speech· B/P· H/R· RR· Weight· UBW%· Orientation tests· Short memory· Calculation· Language · Judgment· Abstract
koplik's spots
blue-white spots w/red halo of oral mucosa; early sign of measles
pulsus bisferiens
2 peaks with a dip in between
the heart has 3 layers, the middle layer is called
myocardium layer
What number nerve is the trigemianl nerve?
the 5th nerve
Dislocation
One or more joint bones is out of position.
Dr. Davenport Nutrition Lecture:
How does liver disease effect nutrition?
Unable to effectively synthesize protein
Dr. Davenport Nutrition Lecture:
Serum Protein
Albumin vs. Pre albumin
Serum Protein: Identifies protein the body stores
 
Albumin: Visceral protein status (not early indicator)
Prealbumin (short half life of 2 days) more senstive to recent changes in protein status - good indicator of recent protein loss
First auscultate the ...
Start in the Right Lower Quadrant, then procede by listening to the LLQ, LUQ, RLQ (not sure about that order but I know the Right Light Quardrant is first)
Unstageable Pressure Ulcer
Full thickness tissue loss in which the base is completely covered by slough and/or eschar
 
what is ptosis?
drooping of the upper eyelid over portion of pupil- could be related to muscle weakness or excessive skin
Developmental Care
Pregnant Female
Increased Tidal Volume
The pregnant mother needs enough air for her and the fetus - Diaphgram elevates 4 cm - but the pregnant female adds 6 cm to the circumference of the chest cage - this increases the tidal volume
malocclusion
when you bite down, do your back teeth meet
The doctor has asked you to bring him an opthalmoscope. You know that he will be examining what part of the patient?
Eyes
whispered pectoriloquy
ask the person to whisper a phrase like "one two three" as you auscultate
paroxysmal nocturnal dyspnea
awakening from sleep with SOB and needing to be upright to achieve comfort
eyes and vision
examiniation fo the eyes include s assessment of visual acuity-teh degree of detail an eye can discern in an image, ocular movementvisual fields-the area an individual can see when looking straight ahead, and external structures
s/s of migraine h/a
throbbing, unilateral pain, N/V, with photophobia
thorax and lungs
assessing the thorax ans lungs in frequently critical to assessing th clients aeratin status
the base of the lungs-posterior
expands to T10-T12 during deep inspiration and rise to about T9 during expiration
Lab Results:
What to triglyceride tests measure?
Screen for hyperlipidemia and etermine risk for C.A.D
 
Borderline: 250-500mg/dl
High: 500mg/dl <
Special Procedures & Findings:
Inspiratory Arrest (Murphy's Sign)
While palpating the liver, ask the client to take a deep breath; if pain occurs, inflammation of teh gallbladder could be present
Abnormalities on Palpation of Enlarged Organs:
Enlarged Kidney
Enlarged with hydronephrosis (usually caused by obstruction of the free flow of urine from the kidney, leading to progressive atrophy of the kidney), cyst (closed sac having a distinct membrane and division on the nearby tissue. It may contain air, fluids, or semi-solid material) or neoplasm (new growth)
 
Difficult to distinguish between enlarged spleen and kidney; however, spleen has sharp edges whereas kidneys never do
 
Spleen retains splenic notch, where as the kidney has no palpable notch
 
Percussion over spleen is dull, where as over the kidney it is tympanitic b/c of the overriding bowel
Dr. Davenport, Lecture Question
What is Crepitus?
What does it feel like?
What is different crepitus feature on men?
 
What is crepitus? – Popping sound – May be a punctured Lung (Called Anumothorax) – Air that gets out of the lung and rest in skin tissue – will feel crunchy during palpating – Its SubQ Air or SubQ Emphazema
  Note where the crepitus – men get incredibly large testicles and penis – because of escaped air
  Feels – like bubble wrap that is easy to pop
  Patient will need something to fix the hole in their lungs
Where are ribs 1-12
Ribs 1-7: Attached directly to the sternum
Ribs 8-10: Attach to the costal cartilage above
Ribls 11-12: Floating
What is the equation for BMI?
BMI= kg/(m^2)orBMI= lbs/(in^2) x 703
<18.5 %
What is the BMI for an under weight person
How many spinal nerves are there and what are they called?
31 pair, dermatomes
age at which apex is found @ 5th intercostal
7 y/o
what are the major assesments in assessing mental
language, orientation, memory, attenmtion span and calculation
what indicates spleen enlargement
percussing on 9-11 ICS LAAL results in dullness upon deep inspiration (spleen should move to accomidate lung)
How to determine splenomegaly?
 
What is splenomegaly?
If site changes to dullness instead of tympany during inspiration, sign of splenomegaly.
 
Splenomegaly is an enlargement of the spleen
Infant & Children
True or False
Percussion is useful in the newborn Respiratory Assessment.
False. Percussion is useless in the newborn because the adult's fingers are too large
The only thing that can be percussed is HYPERRESONANCE in infants with thin chest walls.
Where would you expect to hear "tympany" during a physical exam? (while percussing)
Air-filled viscus: stomach and intestines
"spoon" nails
what may the nails of a person with a chronic iron deficiency look like?
Describe how the following cultures possibly react to pain. Asians - hispanics –Native Americans - Japanese –Kenyans - Italians -
Asians - stoic hispanics – vocal Native Americans - stoic Japanese – stoicKenyans - stoic Italians - vocal
factors on color of areola
parity (# of pregnancies, length of pregnancies), skin tone
what is a reflex
an automatic response of the bodyto a stimulus, it is not voluntarily learned or conscoius
Dr. Davenport Nutrition Lecture:
Kwashiorkor
Diet of mostly carbs with little or no proteins and under stress (Infections, surgery, rauma, burns)
What will enhance the voice sounds making the words more distinct?
Consolidation or compression of lung tissue; solidification in a firm dense mass; may contain fluid instead of air
purpose of the mouth and throat
emit air for talking and breathing, passageway for food and liquids, begin digestion, identify tastes (CN IV), protect from aspitation
Common conversions temperatures:
104F = 40 C98.6F = 37 C95.0F = 35 C
How are health assessments done or conducted
Health assessments start with a general survey that involves observation of the clients general appearance and mental status, and measurements of vital signs, height,& weight
angle of louis (sternal angle)
at 2nd rib (where top of sternum and manubrium meet)
What are 2 tests that can be preformed to distinguish betweeen ascites (fluid inthe peritoneal cavity) or gaseious distention?
Fluid Wave Test
Shifting Dullness Test
What could you do to train yourself not to "rush" into the assessment and remind yourself to thoroughly inspect the patient?
Perform inspection while holding your hands behind your back
arterial obstruction on the side with the lower reading
What may a blood pressure difference of more than 10-15mmHg in the two arms indicate?
describe the normal sounds of the heart
the normal first 2 sounds are produced by closure of the valves of the heartS1-occurs when the atrioventricualr(av) valves close (lub) these valves close when the ventricles hae been sufficiently filled , after the ventricles close empty their blood into the aorta and pulmonary arteries the semilunar valves close producing the second heart soundS2=Dub has a higher pitch than s1 and is also shorter these 2 sound occur within a second or less depending on the heart rate
how do we hear
Sound transmission and hearing are complex processes. in brief, sound can be transmitted by air conduction or bone conduction
1 a sound stimulates the external canal and reaches the tympanic memebrane
2 the sound waves vibrate the tympanic membrane and reache the ossicles
3 the sound waves travels fromt eh ossicles to the opening in the inner ear
4 the cochlea recieves the sound ibrations
5 the stimulus travels to othe auditory nerve(8th cranial nerve and the cerebral cortex

Bone conducted sund transmission occurs when skull bones transport the sound directly to the auditory nerve
Liver span can be interfered with ..
Dullness heard in the lungs due to consolidation or dullness heard in the abdomen due to preganncy, gas distention, or ascites (fluid accumulation)
How should a BP cuff fit?
No more than 2/3 of the entire upper arm. It should not be too loose or too tight and it should be 1 inch above the antecubital fossa.
what are the imaginery lines on the chest
these lines help the nurse identify the position of underlying organs and to record abnormal assessmentsMidsternal linevertical line running through the the center pf the sternumMidclavicular line-vertical lines running midpoint of the clavicleAnterior axillary line-vertical lines anterior axillary folds
what organs are in the left upper quadrant
stomach left lobe of liver, stomach, spleen, pancreas, left adrenal gland
What must be considered when examining the older adult?
1. Base the pace of the examination on the patient's individual needs and abilities.2. Use physical touch to offset the disadvantages of diminishing vision and hearing.3. Beware that loss is inevitable and adaptation to loss affects health status.
Where should you take the pulse on a child under 2 years of age?
Apical (1 min)(after 2 years of age you can use the radial pulse)
In a pt with coarctation of the aorta will the thigh BP be lower or higher?
Lower. (normally a thigh BP is higher but with this congenital narrowing of the aorta you can expect a lower BP. Why? the blood supply to the thigh is below the constriction.
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Term:
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