1180 Flashcards

Question

BP above expected range

Answer 1

Hypertension (HTN)

Answer 2

Hypotension

Answer 3

Orthostatic/postural hypotension

Answer 4

difference between systolic and diastolic BP should be about 40

Answer 5

heat or cold in degrees in body, regulated by hypothalamus, 36.5-37.5 c

Answer 6

rectal, tympanic

Answer 7

skin, oral axilla

Answer 8

Impacting Accuracy Have they had sometime cold or hot to drink/eat Smoking or chewed gum Receiving oxygen Oral surgery or mouth ulcers Skin breakdown in axillary region

Answer 9

substance that produces fever

Answer 10

substance that combats fever

Answer 11

Diaphoresis/Diaphoretic

Answer 12

Ventilation by rate (#), rhythm, depth and effort of respiration Diffusion and perfusion - indirectly via SpO^2

Answer 13

Count for 60 sec or Count for 30 sec and X 2 60 if … Children Irregular respirations Very fast or very slow respirations Should be done with heart rate > feel pulse after you count, still hold their wrist and do RR assessment so they don’t know therefore change their RR.

Answer 14

Younger (higher) Exercise (higher) hypothermia (lower) Anxiety (higher) Smoking (higher) Upright body position (lower) opioid/narcotic medications (lower) Medical conditions (higher) (anemia)

Answer 15

measurement of oxygen in patient’s blood Light source reads patient’s RBC and determines percent of those hemoglobin is bound to oxygen 92

Answer 16

Ensure finger is all the way in the probe Ensure finger has good circulation Ensure the light is against the nail bed Hold the patient’s hand if tremors Is patient moving around a lot, restless/agitated Nail polish/fake nails can interfere with accuracy

Answer 17

Universal symptoms Primary reason why people access health care Affect function and quality of life

Answer 18

PNS fibers carry painful stimuli to CNS Activated by thermal, mechanical and chemical stimuli Starts pathway

Answer 19

Sensory: physical, action in nerves Emotional: how pain makes us feel, fear Cognitive: effect of pain on behaviour, coping strategies Social: how we react and respond

Answer 20

Duration: acute or chronic Frequency: continuous vs. intermittent vs. episodic Form: nociceptive vs. neuropathic Associated with Cancer: with cancer or cancer treatment

Answer 21

Nociceptive -Visceral -Somatic -Cutaneous -Referred -Parietal Neuropathic -Phantom limb pain

Answer 22

Age Gender Culture Spiritual Family Level of anxiety Coping fatigue

Answer 23

Observe and monitor changes -following up with there pain

Answer 24

OLDCARTSS Numeric rating scale Severity scale Visual scale/ FACES pain scale

Answer 25

temporal language comprehension

Answer 26

frontal speak production

Answer 27

balance, coordination, movement, proprioception

Answer 28

12 pairs Each have sensory (5 senses), motor (movement) or both function

Answer 29

8c, 12 t, 5 l, 5 sacral, 1 coccygeal

Answer 30

Signs of neurological emergency Facial drooping, arm weakness, speech difficulty, time to call 911

Answer 31

Presenting with headaches Presenting with facial drooping Presenting with head injury Presenting with dizziness Presenting with limb weakness Presenting with difficulty speaking

Answer 32

Vital signs Level of consciousness using GCS (LOC) Cranial nerves 1-12 Speech Strength testing Cerebellar function Sensation testing Reflexes (advanced)

Answer 33

Helps identify signs about increased intracranial pressure Decreasing pulse Decreasing respirations Decreasing oxygen saturation level Increasing BP Widening pulse pressure > pulse pressure difference between systolic-diastolic, normal 40

Answer 34

Universal system for assessing extent of consciousness impairment (low # bad, high good) 3 components: eye opening, verbal response, and motor response Lowest score 3, highest 15

Answer 35

Mild deficit: 13-14 Moderate deficit: 9-12 Severe: deficit: 8 or less

Answer 36

eyes open... spontaneously speak shout shake pain/pressure (pen pressed on nail bed, squeeze trapezius)

Answer 37

Orientation includes person, place and time Who they are, where are they (city) and what day it is (10 day grace period) Oriented: speaking and answer all questions appropriately Confused: responds to questions, but answers are wrong Words: responds only with inappropriate words (answer doesn’t make sense/ not related to Q) Sound: speech is incomprehensible None: no verbal response

Answer 38

If patient can follow commands (touch your nose, make a fist, squeeze my hand) Do this if the cannot follow commands Localized: patient attempts to use other hand to remove painful stimuli Normal flexion: patient attempts to pull away from painful stimuli abnormal flexion/extension: decorticate/decerebrate posture None: no response to pain Don’t mime the action for them

Answer 39

severe damage to the brain abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward extension

Answer 40

an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight severe damage to brain flexion

Answer 41

means all findings are normal for eye assessment

Answer 42

testing oculomotor nerve (cranial nerve III) and optic nerve (cranial nerve II) assessing Pupil size, equality and shape, direct light reflex, consensual light reflex, accommodation

Answer 43

measure pupil size mm, should be the same

Answer 44

pupils should constrict in response to light Patient should focus at object in the distance

Answer 45

pupils should constrict when light source is aimed at the opposite pupil

Answer 46

hold pen/finger 12 inches from clients face and bring it to their nose -Both pupils should constrict equally and turn inward simultaneously Only one you can’t do if someone is unconscious

Answer 47

CN VII- facial nerve Test for motor function: Raise eyebrows Frown Eyes clenching Show teeth Smile Puff out cheeks

Answer 48

CN IX and X -glossopharyngeal and vagus Test for motor function: ‘Ahh’ -uvula and palate rise Gag reflex

Answer 49

Broca’s area -understand language but can’t form words To test: ask the patient to identify 3 objects and their purpose

Answer 50

Wernicke’s area - poor comprehension, speech is fine, impaired meaning To test: ask patient patient to Point to ceiling Close eyes Can you answer this question does a stone sink in water

Answer 51

weakness in arms Sit patient up in bed/chair Close eyes Hold arms straight out in front, palms up, shoulder height * Hold position for 20 seconds If present, arm on one side will be weak and therefore fall and drift across body Hand will pronate (bad)

Answer 52

walking pattern that's characterized by slowness, stiffness, and difficulty turning Tests for cerebellum function >balance

Answer 53

Tests for cerebellum function >balance

Answer 54

Rapid alternating movements tests for coordination Finger to finger test Finger to nose test Heel to shin test

Answer 55

test upper motor neurons for movements Stroke lateral aspect of foot -normal response to flexion (sad feet) -abnormal response is happy feet for adults

Answer 56

Strength -should be equal on both sides Ex. hold out arm resist my pressure

Answer 57

Constipation increases intracranial pressure -spinal cord

Answer 58

Traumatic brain injury

Answer 59

cerebrovascular accident >stroke

Answer 60

level of consciousness glasgow coma scale

Answer 61

Increased intracranial pressure

Answer 62

Anisocoria

Answer 63

paresthesia

Answer 64

Presyncope - The sensation of almost fainting Syncope - Fainting

Answer 65

CN II sensory vision

Answer 66

CN III motor function vision

Answer 67

CN VII sensory and motor function facial movements

Answer 68

CN IX sensory and motor function information to your mouth and throat

Answer 69

CN X sensory and motor function controls specific body functions like digestion, heart rate and immune system

Answer 70

process when air moves in and out of lungs

Answer 71

movement of gases between alveoli and capillaries

Answer 72

process by cardiovascular system pumps blood throughout the lungs

Answer 73

hemorrhage

Answer 74

substernal/costal indrawing Intercostal indrawing Scalene and sternocleidomastoid Tracheal tug Nasal flaring Tripod position

Answer 75

coughing up blood from the lung(s)

Answer 76

Listening to the lungs using the ladder approach Make sure you listen to a full breath in and full breath out never do it over clothing

Answer 77

front you hear all lobe, back you miss right lobe RML back easier to hear

Answer 78

Suprasternal notch Angle of Louis (sternal angle) Scapular, mid clavicular, midaxillary lines Cervical vertebra 7

Answer 79

Consent!!! Telling them what you will do before doing it and when your putting your stethoscope Keeping them as covered as possible but still be accurate, and tell them when done to cover themself Go in confidence, don't make it awkward

Answer 80

normal Hear over trachea loud, hollow tubular sounds High pitched

Answer 81

Soft, low pitched, rustling> during inspiration Majority of lung sounds -normal

Answer 82

Sounds are a mix of bronchial and vesicular -Mid chest -normal

Answer 83

Brief, discontinuos, popping lungs, high pitched Usually mean fluid in lungs -not normal

Answer 84

Brief, popping lung sounds, thicker sounds Ie. pneumonia -not normal

Answer 85

-not normal Musical sounds caused by narrowing airways (almost sound like a shitty flute) ie. asthma, COPD

Answer 86

not deep enough breaths allows secretions and fluid to build up in lungs and can have bacterial -help by walking, deep breathing and coughing exercises

Answer 87

Nose breathers Hear more bronchovesicular sounds Use mostly diaphragm compared to adults (more abdominal movements) At 2, use more intercostal muscles Respiratory rhythm is irregular Apnea should never exceed 15 sec

Answer 88

Increase in tidal volume (for fetus) Diaphragm rises and costal angles widens to accommodate for enlarging uterus

Answer 89

Decrease in surface area (alveoli gets fibrose) Lung capacity decrease b/c muscle weakness More dead space and less vital capacity Often thoracic spine curves (barrel chest)

Answer 90

Family history Increased age Ethnicity Sex, men have higher risk until women reach menopause High BP Obesity High blood sugar Elevated cholesterol

Answer 91

Pain Diaphoresis Dyspnea Edema Pressure on chest

Answer 92

History Demographics OLDCARTSS Associated symptoms Respiratory concerns Lifestyle Family and past history Exertion causing chest pain

Answer 93

General survey Skin colour Respirations Speech pattern Diaphoresis Nail beds Abnormal pulsations

Answer 94

At 5th intercostal space at mid clavicular line Brisk tap Checks size of the heart (if enlarged <3, brisk tap is down and laterally)

Answer 95

Aortic valve: 2nd intercostal space, right sternal border Pulmonic valve: 2nd intercostal space, left of sternum Tricuspid valve: 4-5th intercostal space, left sternal border Mitral valve: 5th intercostal space, midclavicular line

Answer 96

Loudest at apex Closure of mitral and tricuspid valves Beginning of systole

Answer 97

Loudest at base (top) Closure of aortic and pulmonic valves Beginning of diastole

Answer 98

turbulence causing swooshing or blowing sounds made by rapid, choppy (turbulent) blood flow through the heart.

Answer 99

-turbulent blood flow usually by partial obstruction -whooshing sound when you place stethoscope over carotid arteries

Answer 100

Increase collagen decrease elastin Decrease HR and increase BP Cardiac valves become thicker and stiff Decrease number of pacemaker cells in SA node Arteries get thicker

Answer 101

Assess circulatory function of extremities and nerve function Test sensation and motion

Answer 102

sensation between big and 2nd toe motion-dorsiflexion

Answer 103

sensation on sole, Motion plantar flexion

Answer 104

S between thumb and pointer, hyperextend fingers

Answer 105

s pinky, m abduct fingers

Answer 106

s pointer finger, m opposition

Answer 107

pain is aching, dull heavy Pain and edema relieved when legs elevated Varicose veins Edema Brownish colour to skin

Answer 108

swollen and twisted veins

Answer 109

intermittent claudication Relieved by short rest Pale when leg elevated, rubor with dependency Cool temp

Answer 110

buildup of fats, cholesterol in and on artery walls

Answer 111

muscle pain that happens in your legs when you're active and then stops when you rest

Answer 112

Movement (assess nerve function) Temperature Sensation (assess nerve function) Blanching (capillary refill) Colour Edema Pulse

Answer 113

0- no pitting 1-mild 2- moderate 4mm lasts 10-15 sec 3- moderately severe 6mm, over 1 min 4+ severe 8mm, over 2 min

Answer 114

stomach, small intestine and large intestine/colon

Answer 115

right upper Q, left upper Q, right lower Q + left lower Q Lower quad use symphysis pubis

Answer 116

ascending and transverse colon, gallbladder, liver, pancreas (head), pylorus, R adrenal gland and kidney, right ureter

Answer 117

spleen, stomach, transverse descending colon, pancreas (body and tail), left adrenal gland and kidney, left ureter

Answer 118

Appendix, ascending colon, cecum, right kidney, right ovary and tube, right ureter , right spermatic cord

Answer 119

sigmoid colon, left kidney, left ovary and tube, left ureter, left spermatic cord

Answer 120

bladder, uterus + prostate gland

Answer 121

Abdominal pain Indigestion Anorexia (lack appetite not ED) Nausea, vomiting, hematemesis dysphagia/odynophagia Change in bowel function urinary/renal symptoms Menstrual symptoms Dental issues Dehydration Jaundice

Answer 122

gnawing burning, cramping, aching Organ pain

Answer 123

constant, localized, steady, aching or sharp Inflammation of peritoneum

Answer 124

hematemesis

Answer 125

Do you ever feel nauseated before/after a meal? (how often?) Does this happen with a specific type of meal? How does this impact your appetite? Are you able to ingest food/fluids when you feel nauseated? If so, how much

Answer 126

When you feel nauseous, do you vomit? If yes, what does it look like? (volume, consistency, colour, frequency, timing) hematemesis Effect on appetite/ability to tolerate intake Do you have food allergies? Have you travelled/eaten out recently

Answer 127

Do you have problems chewing solid foods? History of stroke, brain trauma, seizures? Problems with lethargy? Do you wear dentures?

Answer 128

Any difficulties swallowing thin or thick fluids? Are there problems with the volume of food? Do you feel as though food gets stuck? Do you cough after sipping a drink?

Answer 129

nothing by mouth

Answer 130

Frequency Consistency Amount Colour Odour Presence of blood or mucous What do you take to have a bowel movement (supplements, laxative)

Answer 131

normal -vitamin a -antacid with AlOH

Answer 132

0normal -green, blue, purple food -food coloring -chlorophyll

Answer 133

c-diff bacteria -infection

Answer 134

mal-absorption, hepatitis or gallbladder disorders

Answer 135

blood -fresher lower gi

Answer 136

hematochezia

Answer 137

upper gi bleed if black and tarry =melena iron beets

Answer 138

Body weight Skin mouth/lips/tongue Teeth Swallowing Appearance of stool, urine and emesis umbilicus Peristaltic wave, pulsations Contour, size, shape, symmetry *Observe from both end and side of bed with patient lying flat

Answer 139

scaphoid + protuberant

Answer 140

-sounds normal RLQ-RUQ-LUQ-LLQ b/c ileocecal valve Documentation (bowel sounds in all 4 Q)

Answer 141

where small and large intestine meet

Answer 142

Constipation Diarrhea Meds Mechanical obstruction Paralytic ileus Chronic conditions diet/activity/fluid intake

Answer 143

Have patient empty their bladder first Light palpation (1 hand) Use a rolling, dipping motion Use a Pattern Palpate painful areas last Normal finding: soft, non-tender/no pain abdomen

Answer 144

ask Q + oldcartss Inspection Auscultation Palpation percussion

Answer 145

Disease or disability Fluid balance Meds Pelvic floor muscle tone Psychological factors

Answer 146

A health individual should produce 0.5 ml/Kg per hour (0.5 ml/Kg/hr)

Answer 147

Change in V or quality of urine produced Renal obstruction continence/retention Dementia, mobility restrictions, and neurological changes

Answer 148

Voluntary and involuntary control Helps support pelvis organs and prevent urine loss (helps you hold it) Weak PFM contributes increase genitourinary problems

Answer 149

Embarrassment, anxiety + environmental factors Increase urgency, frequency, and retention

Answer 150

Review client’s normal urinary pattern (frequency, time of day, volume, color, odor) History of pain and associated symptoms Contributing factors

Answer 151

Inspect skin, mucous membranes Perineum: skin breakdown, atrophy Insect bladder area

Answer 152

Clarity Odour Volume Sediment, mucous, or blood Lab test results

Answer 153

More common in females Risk factors: incontinence, catheterization, hygiene, stasis of urine, intercourse, tampon use, residual urine Symptoms: burning when peeing, frequency, urgency, hematuria. Foul odour, pelvic pain, fever

Answer 154

Dyspnea Crackles in lungs pitting edema in lower legs, edema in arms and legs fatigue

Answer 155

Impaired cognitive function Headaches. fatigue, sunken eyes Dry skin Paeds: sunken fontanelles, lacks tears Hypotension Oliguria: low urine output

Answer 156

Rapport first, then assessment Be careful of your language No leading Qs + assumptions Be therapeutic

Answer 157

Assess function of muscles, joints and bones

Answer 158

Exercise falls/injury Diet Weight Alcohol Smoking sun exposure

Answer 159

Demographic data Past medical history Family history Nutrition and medication Psychosocial history > how does your mobility affect you socially? Occupation, lifestyle, behaviours >are there safety issues for you at home? Functional assessment> what problems do you have with mobility?

Answer 160

Legs Genu verum/bowlegged until 18 month Genu valgum/knock-knee Legs straighten by 6-7 years Fontals Anterior closed by 18-24 month Posterior closed by 2 months Back Check for scoliosis

Answer 161

Increase level of circulating hormones may increase mobility of joint Changes in posture Centre of gravity shifts Strain or lower back muscles and pain in late pregnancy Sciatic nerve pain

Answer 162

Fall prevention and safety Changes in mobility and balance Osteoporosis and decreased bone density Sensory impairments

Answer 163

Integrated with associates joint for range of motion -compare bilaterally Full strength requires complete active range of motion Grade scale 1-5

Answer 164

a joint that is frozen in place due to shortening of muscles, tendons, ligaments or skin

Answer 165

walking pattern

Answer 166

involuntary contraction of muscle fibers -only for few sec

Answer 167

involuntary contraction of muscles -neuro condition that causes rhythmic shaking

Answer 168

sudden violent involuntary contraction of a muscle

Answer 169

Range of motion Move all joint Do not move to point of pain Active vs passive Prevention of joint stiffness, muscles shortening, contractures

Answer 170

posture Static and dynamic Gait locomotion/movement Balance Cerebellum, neuro component Coordination Coordination of movement, neuro component Joints, muscles and extremities Size Symmetry Contour Colour Edema Facial expression with use Curve of spine

Answer 171

active you do yourself passive person assists you

Answer 172

Muscle tone Temperature variations tremor/fasciculation Edema Crepitus Bony articulation tenderness

Answer 173

Nutrition status Immobility UV exposure

Answer 174

Education on features of a benign mole Decreasing UV exposure Emphasize steps in skin self-examination

Answer 175

Asymmetry: shape is different than other side Border: irregular, ragged and imprecise Colour: colour variation with brown, black, red, grey or white within lesion Diameter: melanoma is usually more than 6mm in diameter Evolution: look for change in colour, size, shape or symptoms

Answer 176

Family history Past history Medications Do they use sunscreen? Lifestyle, occupational, history and personal behaviours

Answer 177

Inspection Palpation Document findings If client has a concern about skin, inspect area/lesion first and ask other questions second

Answer 178

Inspect all body areas Note colors and pigment compared to patients skin tone Abnormalities (cyanosis, pallor, jaundice, erythema, swelling) inspect individual lesion (if elevated, solid, fluid-filled) (pattern morphology, size, distributions, body location) Observe growth, tumours Any wounds or incisions Pressure ulcers Burns Hair and nails Ask the patient to roll over in bed - check bony prominences (heels, coccyx etc…) for signs of pressure ulcer

Answer 179

Location Distribution Localized Regional Generalized Primary vs. secondary Margins/borders morphology> papule, pustule, macule Colour Texture, consistency Size

Answer 180

blue spots on babies, clusters of skin pigments, normal

Answer 181

indicates early stage skin irritation or hyperemia ( increase blood flow). Skin is still healthy and can recover

Answer 182

suggests the skin has sustained damage to deeper layers. Often associated with pressure ulcers or tissues injury. Often first sign of pressure ulcer

Answer 183

Assess skin temp, moisture and texture Assess skin turgor (best place is below clavicle Palpate lesions for tenderness, mobility and consistency Palpate hair and nails

Answer 184

flat/non-palpable spot, typical discolours (ex. freckles) Primary Skin Lesion

Answer 185

raised, solid, palpable, less than 1 cm in diameter, border well (ex. Mosquito bite) Primary Skin Lesion

Answer 186

raised, red or pale skin patch that itches or burns. Vary in shape or size (hives) Primary Skin Lesion

Answer 187

small, thin walled, fluid filled sacs (ex. Herpes simplex blister) Primary Skin Lesion

Answer 188

raised, pus filled, clear edges (acne) Primary Skin Lesion

Answer 189

encapsulated sac filled with fluid or solid matter. Located in the upper layer of skin (ex. Epidermal cyst) Primary Skin Lesion

Answer 190

-initiate lesion -changes to primary skin lesion bc of factors (scratching)

Answer 191

fibrous replacement of local skin structure (surgical scar) Secondary Skin Lesion

Answer 192

skin breakdown caused by repetitive scratching/rubbing Secondary Skin Lesion

Answer 193

loss of skin face, extending into dermis, subcutaneous, fascia, muscle, bone or all (pressure ulcer) Secondary Skin Lesion

Answer 194

A state of well-being where an individual realizes their own abilities can cope with normal stress in life, can work productively and is able to make a contribution to their community.

Answer 195

Interpret reality accurately Have a healthy self-concept Can relate to others Achieve a sense of meaning in life Demonstrate creativity/productivity Have control over their behaviour Adapt to change and conflict

Answer 196

-A person can experience good mental health while living with a mental disorder -Mental health and mental disorders should not be viewed on the same continuum

Answer 197

* Over extended period of time and interfere with normal, everyday functioning Decrease emotional expression Self-concept changes Depressed mood Occupational problems Decrease motivation Insomnia nervousness Disorganized thoughts

Answer 198

how the patient reports they feel

Answer 199

the observable expression of an individual’s emotional state as seen through facial expression, body language and tone of voice

Answer 200

used for screening, diagnosing, monitoring and measuring the severity of depression

Answer 201

questionnaire designed to assess the severity of generalized anxiety disorder symptoms

Answer 202

test for alcohol use disorder in adults

Answer 203

When a client is over 80 years old When a client presents with a change in behaviour or mood After a client has a stroke After treatment for delirium/depression New difficulty with driving (near misses)

Answer 204

a class of disorders characterized by the progressive deterioration of thinking ability and memory as the brain becomes damaged with no change in consciousness

Answer 205

-serious and sudden change in mental abilities -impaired attention, altered level of consciousness, -Causes can be meds, infection, dehydrate

Answer 206

One of first tools used to assess cognitive function Not used much today Tests numerous aspects of cognition *Ex. patient name 3 common objects and repeat the names of those objects later in assessment

Answer 207

A quick and initial screen for cognitive impairment Useful in determining when further assessment may be needed

Answer 208

Highly sensitive tool for early detection of mild cognitive impairment

1180 Flashcards

(250 cards)