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Assessment Unit 2 Flashcards

(102 cards)

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1
Q

The nose

A

Warms, moistens and filters the inhaled air is the sensory organ for smell

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2
Q

What does the external knows have

A

Nares, columella ( septum)divides the two ,also the ala widens into the vestibule

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3
Q

What do the turbinates do

A

Warm humidify and filter the inhaled air

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4
Q

With the penlight what inside the nose will you see

A

The inferior and middle turbinate

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5
Q

What sinuses can you palpate

A

The frontal and the maxillary

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6
Q

What sinuses are deeper in the skin

A

The ethmoid and the sphenoid

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7
Q

How do you test the latency of the nostrils?

A

By pushing each nasal wing shut with your finger while asking the person to sniff inward

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8
Q

The sense of smell is mediated by what nerve?

A

Cranial

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9
Q

How should you have the head when inspecting the nose

A

Erect and tilted back

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10
Q

What happens with the aging adult in the nose

A

A gradual loss of subcutaneous fat making the nose appear more prominent

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11
Q

What do the nasal hairs do in an aging adult

A

Grow coarser and stiffer and may not filter the air as well, The hairs protrude and may cause itching and sneezing

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12
Q

What can clipping the nose hairs do

A

Cause infection

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13
Q

While May the sense of smell diminish

A

Because of decrease in the number of olfactory nerve fibers

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14
Q

After what age does the decrease in the sensation of smell begin

A

60 years and continues progressively with age

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15
Q

The nurse is assessing a patient for sinus tenderness how should the nurse perform the examination

A

Press firmly around the orbit of the eyes and palpate the nose noting pain

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16
Q

What are you looking for when inspecting the nose

A

Polyps

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17
Q

What are polyps

A

Benign growth that accompany chronic allergy

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18
Q

What is rhinorrhea

A

Discharge from nose can occur with cold allergies sinus infection and trauma

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19
Q

With discharge what do you document

A

Color consistency and volume

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20
Q

What is the first segment of the respiratory system

A

Nose

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21
Q

What’s an abnormal amount of colds

A

Greater then two times a year

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22
Q

Where is the most common site of nosebleeds(epistaxis)

A

Kiesselbach plexus

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23
Q

What does smoking do?

A

Decrease their sense of smell

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24
Q

What are you inspecting when looking at the nose

A

Symmetric, in the midline, deformities inflammation and skin lesions

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25
What can trauma in the nose cause
Deviated septum and obstruction
26
Seasonal
Pollen
27
Perennial
Allergen or dust
28
Treat epistaxis
Sit up head tilted forward pinch nose between thumb and forefinger for 5-15 minutes
29
What does absence of sniff indicate
Obstruction common cold nasal polyps or Rhinitis
30
Rhinitis
Nasal mucosa is swollen and bright red with uri
31
What does the inside of the nose look like with chronic allergies
The mucosa looks swollen boggy pale and grey
32
Deviation
A deviated septum is common and is not significant unless airflow is obstructed
33
What does a deviated septum look like
A hump or shelf in one nasal cavity
34
What does the inside of the nose look like normally
Pink and free of discharge
35
smooth, pale, gray, avascular mobile non tender
Polyps
36
Palpate the sinus areas
Use thumbs Press the frontal sinus by pressing up and under the eyebrows below cheekbones person should feel pressure but no pain
37
Abnormal sinuses
Tender to palpating,swelling and puffiness
38
Transillumination
No evidence to support the practice
39
Acute allergies
Darker pink
40
Inspection of sinuses
Swelling, puffiness
41
Where is the suprasternal notch
A u shaped depression just above the sternum in between the clavicles
42
Where is the sternal angle
Continuous with the second rib
43
What's another name for sternal angle
Angle of Louis
44
What is the angle of Louis important for
Cardiac and respiratory
45
Where do you listen to lung sounds
Not on a bone
46
What's below the xiphoid process
The costal angle
47
What is the measurement for the costal angle and the costal margin
90°
48
What happens with inspiration
Increase vertical diameter, increased AP diameter diaphragm descends as it contracts
49
What happens with expiration
The diaphragm relaxes
50
What happened with the costal cartilage in an aging Adult
They become calcified which produces a last mobile thorax
51
What happened to the respiratory muscle strength after age 50
Declines harder to inflate
52
Aging adult symptoms
Decreased vital capacity increased residual volume less available gas exchange
53
Where is TB most relevant
Mostly in people who are foreign born of racial ethnic minorities
54
How often does asthma occur
5 to 12% of the US population and is the most common chronic disease in childhood
55
Where does asthma not occur often
Lowest amount amount Asian and Hispanic
56
Hemoptysis
Blood in sputum
57
Cold bronchitis or viral infections
White or clear sputum
58
Bacterial infection
Yellow or green sputum
59
Tuberculosis or pneumonia
Rust colored
60
Pulmonary edema sympathomimietic
Pink and frothy
61
Acute illness characteristic of a cough
Continuous throughout day may reflect exposure to irritant at work
62
Night time
Post nasal drip sinitus
63
Chronic bronchitis
History of productive cough for three months of the year for two years in a row
64
Early morning
Chronic bronchial inflammation of smokers
65
Orthopnea
Difficulty breathing when supine
66
Peroxisomal nocturnal dyspnea
Awakening from sleep with shortness of breath meaning to be a break to achieve comfort
67
If next muscles and trapezius muscles are larger than normal
Cystic fibrosis are hyper trophy
68
How to confirm symmetric chest expansion
Please hands on the posterior lateral chest wall with thumbs at the level of T9 or teatime slide your hand medially to pinch up a small fold of skin between your thumb and ask the person to take a breath
69
Assessing tactile or vocals for Fremitus
Used to own their edge of one hand and touch the person's chest wall as they repeat 99
70
COPD
Neck muscles are hyper trophy need they often that and a tripod position waiting for word and arms bring their knees
71
Unequal chest expansion
Occurs with Atelectasis, lobar pneumonia pleural effusion are with their ass licked trauma or with fractured ribs
72
Transverse diameter
1:2
73
Strider
High pitched, crowing louder in neck; croup acute epiglottis
74
Wheeze low pitched
Single note, snoring heard throughout; bronchitis
75
Wheeze high pitched
Musical squeaking can occur exhale inhale more dominant in exhale; acute asthma or chronic emphysema
76
Pleural friction rub
Superficial sound course located inhale and exhale pleuritie
77
Atelectasis crackles
Find crackles but don't last Heard an axilla and bases in aging adults
78
Crackles
Mild low pitched bubbling in gurgling sound like Velcro pulmonary edema Pneumonia
79
Crackles-fine
Just continuous high pitched short crackling and popping sound; pneumonia heart failure
80
Tachypnea
Rapid shallow breathing
81
Bradypnea
Slow breathing less than 10
82
Cheyenne strokes respiration
Increase in rate and depth and then decrease last 30 to 45 second with periods of apnea most common cause severe heart failure
83
Hyperventilation
Increased in both rate and depth ;fear anxiety
84
Hypoventilation
And irregular shallow pattern
85
Biot's respiration
Similar to Cheyenne strobes except pattern is irregular
86
Normal adult configurations of the thorax
A ratio of 1 to 2
87
Barrel chest
Not equal more of square lake because of chronic emphysema and asthma
88
Pectins excavatum
Sunken sternum
89
Pectins carnitum
Forward protrusion of sternum
90
Bronchial tracheal
Hi pitch mod amplitude quality harsh hollow tubular in the trachea and larynx
91
Bronchialvesicular
Moderate pitch Munar amplitude quality mixed
92
Vesicular
Low pitch soft amplitude quality rustling like the sound of trees
93
Bronchial (tracheal)
High, loud, harsh hollow tubular
94
Bronchovesicular
Moderate, moderate mixed,
95
Vesicular
Low, soft, rustling like sound of wind in trees
96
Crackles fine
Discontinuous high pitched short crackling during inspirations
97
Crackles coarse
Loud-low pitched bubbling and gurgling sounds
98
Atelectasis crackles
Don't last disappear after first few breaths in aging adults
99
Pleural friction rub
Coarse low pitched, pleuritis accompanied by pain
100
Wheeze high pitched
Diffuse airway obstruction acute asthma or chronic emphysema
101
Wheeze low pitched
Bronchitis
102
Strider
High pitched crowing sound croup acute epiglottitis

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