Chapter 13 Flashcards
Signs?
-Objective data as perceived by the examiner
-Can be seen, heard, and measured and can be verified by more than one person
-Examples: rashes, altered vital signs, visible drainage or exudate -Lab results, diagnostic imaging, and other studies
Symptoms?
-Subjective data Perceived by the patient
-Examples: pain , nausea, vertigo , and anxiety -Nurse unaware of symptoms unless the patient describes the sensation
Disease?
-It is any disturbance of a structure or function of the body; a pathologic condition of the body is
-recognized by a set of signs and symptoms
-Signs and symptoms are clustered in groups to help the health care provider to make a medical diagnosis
Origins of disease example?
- Disease or illness originates from many causes: hereditary, congenital inflammatory, degenerative, infectious , deficiency, metabolic, neoplastic traumatic, and environmental
Unknown etiology?
Diseases that have no apparent cause
look photo 1 physical assignment
ch 13
Chronic?
Are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.
Remission?
The reduction or disappearance of the signs and symptoms of a disease or the period in which diminution occurs.
Acute?
A disease or disorder that lasts a short time, comes on rapidly, and is accompanied by distinct symptoms
Organic disease definition ?
any health condition in which there is an observable and measurable disease process, such as inflammation or tissue damage
-An organic disease is one that can be validated and quantified through the standardized biological measures known as biomarkers
Functional disease?
any condition that results from the abnormal function of cells, tissues, and organs and not the abnormal structure of cells, tissues, and organs.
are the body is letting go through
What is the difference between and infection and an inflammation?
–Infection- invasion of the body by a microorganism
-Inflammation - the body’s response to an invasion or trauma
Three things happen when an organism enters the body ?:
- Body will eliminate the pathogen
- The pathogen will reside without disease
- The pathogen will cause an infectious disease
Inflammation?
Protective response of the body tissues to irritation, injury, or invasion by disease producing organisms
What are the 5 Cardinal Signs of Inflammation?
-Heat
Erythema (Redness)
(increase blood flow are)
Edema-(Swelling)
Purulent -drainage pus and loss of function
Pain
Infection?
Caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites that produce tissue damage
Physical assessment Prepare?
-bring all the item -Nurse also makes use of the senses of touch , smell, sight, and hearing
-Always wash your hands before beginning assessment
-Documentation of the interview and assessment is necessary utilizing facility forms
-Telephone consultation
Virus ?
-Causes viral infections
-Common cold, flu , chicken pox
-Contagious
-Can spread throughout the body
-Cannot be treated with antibiotics
Bacteria?
-Causes bacterial infections
-Strep throat,pneumonia, urinary tract infection
-Sometimes contagious
-Stays in one part of the body
-Can be treated with antibioitcs
Risk Factors for Development
of Disease
-A risk factor is any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other that increases the vulnerability of an individual or a group to illness or accident
-Risk factors do not necessarily mean that a person will
develop a disease condition, only that the chances of disease are increased
-Genetic and physiologic, age, environment, and lifestyle
Assessment?
Process of making an evaluation or appraisal of the patient’s condition
Medical assessment?
Physical examination is conducted by the health care provider
The nurse is often expected to carry out certain functions
Physical assessment item needed ? * choose all apply *
penlight, stethoscope, blood pressure cuff, thermometer, gloves, and a tongue blade
Equipment and Supplies physical in general?
-preparing the exam room
-assist with equipment
-preparing the patient
-collect specimens
Initiating the nurse patient relationship?
-The first interview is the most challenging to conduct
-Introduce yourself and state name , position, and purpose of the interview
-Give an estimate of time
-Ask if the patient has any questions and answer them appropriately
-Communicate trust and confidentiality
-Convey competence and professionalism
The Interview?
- Project relaxed, unhurried manner
-Conduct in a quiet, private, well-lighted setting
-Convey feelings of compassion and concern
-Determine by what name the patient wishes to be addressed
-Nurse should have an accepting posture, relaxed, eye level and pleasant facial expression
The initial step in assessment process Nursing Health History?
-Information on patient’s wellness , changes in life patterns , socio cultural role , and mental and emotional reaction to illness
-Biographic data
-Reasons for seeking health care Chief complaint
-Present illness or health concerns
-Past health history
Nursing health History?
-Environmental history
-Family history
-Psychosocial and cultural history
-Review of systems
Nursing Physicians assessment purpose?
-The purpose is to determine the patient’s state of health or illness
-Initial step of the nursing process and in forming the nursing care plan
-When to perform a physical assessment (-Perform assessment as soon after admission as possible
-Initial assessment is done by an RN
-Ongoing assessment is the responsibility of LPN and RN)
- Methods of nursing physical assessment
Head to Toe assessment?
-Neurologic
-Skin and hair
-Head and neck
-Mouth and throat
-Eyes, ears, and nose
-Chest, lungs, heart, and vascular system
-Gastrointestinal system
-Genitourinary system
-Rectum
-Legs and feet
Documentation?
- Follow institution protocol and forms used for history and physical assessment
-Be objective, clear complete and concise
Telephone Consultation?
-It is essential to follow Health Insurance Portability and Accountability Act (HIPAA) guidelines
-Used in a variety of health care settings
Cultural Considerations?
Culture includes knowledge, skills, art, morals, law, customs, and any other acquired habits and capabilities of a group of people
Ways to develop cultural and ethnic sensitivity?
-Recognize that cultural and ethnic diversity exist
-Demonstrate respect for people as individuals
-Respect the unfamiliar
Frequently noted sign and symptoms of disease conditions?
Part 1
Anorexia
Asthenia
(Decreased muscle strength.)
Bradycardia
Constipation
Coughing
Cyanosis
(a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.)
Diaphoresis
(excessive sweating or perspiration that is not due to physical exertion or warm temperatures.)
Sallow
(of an unhealthy yellow or pale brown color.)
Scleral icterus
(is most often the initial presenting sign of jaundice,)
Tachypnea
Tachycardia
Vomit
Frequently noted sign and symptoms of disease conditions?
Part 1
Dyspnea
Ecchymosis
(a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.)
Edema
Erythema
Fetid
(smelling extremely unpleasant)
Fever
Inflammation
Jaundice
Lethargy
(a lack of energy and enthusiasm)
Nausea
Orthopnea
(Discomfort when breathing while lying down flat; common in people with some types of heart or lung conditions)
Pain Pallor
(Pale skin can have causes that aren’t due to underlying disease)
Pruritus Purulent drainage ) sign infection
Equipment used during a physical examination?
disposable gloves, ophthalmoscope otoscope attachment, sterile safety pin, tuning fork, cervical spatulas, tongue depressor, cotton -tipped swab, lubricant vaginal speculum, reflex hammer, tape measure, penlight, specimen cup, sphygmomanometer, and stethoscope
PERRLA stands for ?
for pupils equal , round , reactive to light , and accommodation .
Wheezes are sounds produced ?
by the movement of air through narrowed passages in the tracheobronchial tree .
Eyes Examination?
Snellen eye chart
Rosenbaum/Jaeger near vision card
Penlight
Cotton wisp
Ophthalmoscope
Eye cover, gauze, or opaque card
Physical Assignment order ?
Inspect
Palpate
Percussive
Auscultate
for all the except when your doing abdomen inspect,auscultate,percussive, palpate -because it can alter the bowel sound
Skull?
-Size ( normocephalic )
-No depressions , deformities , masses , tenderness
-Overall contour and symmetry
Face ?
-CN V MOTOR (5 trigmeinal nerve ): Test the strength of the muscle contraction by asking the client to clench their teeth while you palpate the masseter and temporal muscles
-SENSORY : Test light touch by having the client close their eyes while you touch the face gently with a wisp of cotton . Ask the client to tell you when they feel the touch
-CN VII (7 facial expression) : MOTOR: Test facial movement and symmetry by having the client smile , frown , puff out the cheeks raise the eyebrows , close their eyes tightly , and show their teeth .
Neck ?
-check shoulders equal in height and with average muscle mass
-RANGE OF MOTION (ROM):
-CN XI ( accessory nerve 11) -Place your hands on the client’s shoulders and ask them to shrug their shoulders against resistance; then turn the head 45 degree to see jugular vein
lymph node Palate ?
(Chains of lymph nodes extend from the lower half of the head down into the neck) Palate ?
Palate
-Occipital nodes: Base of the skull
-Postauricular nodes : Over the mastoid
-Preauricular nodes: In front of the ear
-Tonsillar ( retropharyngeal ) nodes : Angle of the mandible
-Submandibular nodes: Along the base of the mandible
-Submental nodes: Midline under the chin
-Anterior cervical nodes: Along the mandible
-Supraclavicular nodes : Above the clavicles
Thyroidal Gland ?
-check neck to see any enlargement of the gland
-Instructing the client to take a sip of water and feeling the thyroid gland as it moves up with the trachea.
-Palpating the thyroid gland on both sides of the trachea for size, masses , and smoothness .
-AUSCULTATION : If the thyroid is enlarged , auscultate the gland using a stethoscope . A bruit indicates an increase in blood flow to the area , possibly due to hyperthyroidism
Trachea?
-Inspect and palpate the trachea for any deviation from midline above the suprasternal notch.
-Masses in the neck or mediastinum and pulmonary abnormalities cause lateral displacement
Test cranial nerves during the eye examination ?
CN II (2 optic ) : visual acuity , visual fields
CN III ( 3 -oculomotor ),
CN IV ( 4- trochlear ),
CN VI (6-abducens): extraocular movements III (oculomotor ): pupillary reaction to light CN V corneal light reflex
-CNI
-CN VIII
and What test?
-CNI ( 1 olfactory): Assess the nose for smell.
-CN VIII (8 auditory): Assess the ears for hearing. -whisper test
Mouth and Throat check?
Lips,gumas,mucous membrane,tongue,teeth
When checking Hard palate?
-Whitish, intact, symmetric, firm and concave .
-Soft palate Light pink, intact, smooth, symmetric, and moves with vocalization
-Uvula: Pink, midline, intact, and moves with vocalization
-Tonsils:The same color as the surrounding mucosa and vary in size and visibility
Speech :Clear and articulate .
-CN XII -( 12 hyoglossal) -let patient sick out to side to side
-CN IX (9 glossopharyngeal )–Gag reflex ?Elicit by using a tongue blade to
- CN IX
-CN XII
-CN IX ( glossopharyngeal ) and CN X ( vagus): Assess the mouth for movement of the soft palate and the gag reflex. Assess swallowing and speech quality.
-CN XII (hypoglossal): Assess the tongue for movement and strength
Vertica Chest landmark ?
look photo
Thorax and Lungs auscultate
-The midsternal: line is through the center of the sternum .
-The midclavicular: line is through the midpoint of the clavicle
-The anterior axillary: line is through the anterior axillary folds.
-The midaxillary: line is through the apex of the axillae.
- The posterior axillary: line is through the posterior axillary fold.
The right and left scapular lines are through the inferior angle of the scapula .
-The vertebral line is along the center of the spine.
Loud , high -pitched , hollow quality, expiration longer than inspiration over the trachea
-Bronchial
AUSCULTATION EXPECTED SOUNDS
: Dry , grating , or rubbing sound as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration
Pleural friction rub
Auscultation UNEXPECTED OR ADVENTITIOUS SOUNDS ?
bubbly sounds ( not cleared with coughing ) as air passes through fluid or re- expands collapsed small airways
Coarse Crackles
Auscultation UNEXPECTED OR ADVENTITIOUS SOUNDS ?
High - pitched whistling , musical sounds as air passes through narrowed or obstructed airways , usually louder on expiration
Wheezing
Auscultation UNEXPECTED OR ADVENTITIOUS SOUNDS ?
Coarse , loud , low - pitched rumbling sounds during either inspiration or expiration resulting from fluid or mucus , can clear with coughing
Rhonchi
Auscultation UNEXPECTED OR ADVENTITIOUS SOUNDS ?
: From collapsed or surgically removed lobes
Absence of breath sounds
Auscultation UNEXPECTED OR ADVENTITIOUS SOUNDS ?
PERCUSSION
Thorax and Lungs?
-Compare sounds from side to side
-Percussion of the thorax elicits resonance .
PERCUSSION
Thorax and Lungs UNEXPECTED FINDINGS AND SIGNIFICANCE ?
Dullness: In fluid or solid tissue , this can indicate pneumonia or a tumor
Hyperresonance: In the presence of air, this can indicate pneumothorax or emphysema .
Auscultatory sites for the heart
look photo
Aortic : Just right of the sternum at the second ICS
Pulmonic : Just left of the sternum at the second ICS
Erb’s point : Just left of the sternum at the third ICS
Tricuspid : Just left of the sternum at the fourth ICS Apical/mitral: Left midclavicular line at the fifth ICS
peripheral vascular system located to assess bruits ?
(A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs)
Carotid arteries: Over the carotid pulses
Abdominal aorta: Just below the xiphoid process Renal arteries:
Midclavicular lines above the umbilicus on the abdomen Iliac arteries:
Midclavicular lines below the umbilicus on the abdomen Femoral arteries: Over the femoral pulses
Inspection assessment the skin ?
Lesions: Bruising, rashes, or other primary lesions
Scars: Location and length Silver striae or stretch marks (expected findings)
Dilated veins: An unexpected finding possibly reflecting cirrhosis or inferior vena cava obstruction
Jaundice, cyanosis , or ascites: Possibly reflecting cirrhosis
Medium pitch , blowing sounds and intensity with equal inspiration and expiration times over the larger airways?
-Bronchovesicular
AUSCULTATION EXPECTED SOUNDS
-Soft, low -pitched , breezy sounds , inspiration three times longer than expiration over most of the peripheral areas of the lungs
-Vesicular
AUSCULTATION EXPECTED SOUNDS
refers to the passive or active removal of fluids from a body cavity, wound, or other source of discharge by one or more methods?
Drainage
refers to fluid, cells, or other substances that are slowly exuded, or discharged , from cells or blood vessels through small pores or breaks in the cell membrane, usually as a result of inflammation or injury?
Exudate
Physical assessment techniques?
-This inspection or purposeful observation , is the technique the nurse uses most frequently
-Palpation, the nurse uses the hands and sense of touch to gather data
-Auscultation is the process of listening to sounds produced by the body
-Percussion is use of the fingertips to tap the body’s surface to produce vibration and sound.
It generally includes data such as birth, gender , address , family members ‘ names and addresses, marital status, religious preference and practices, occupation, source of health care, and insur ance, Medicare, and Medicaid benefits Verify this information with the patient to ensure that it is correct ?
Biographic date
attention is concentrated or focused on a particular part of the body , where signs and symptoms are localized or most active , to determine their significance?
focused assessment
refers to the elasticity of the skin caused by the outward pressure of the cells and inter stitial fluid and Dehydration results in decreased?
Turgor
The normal carotid pulse is regular and palpable without a thrill ?
(a vibrating sensation the nurse perceives during palpation along the artery)
Are abnormal swishing sound head over glands and arteries?
Bruits
fluid in the bronchioles and the alveoli , are short , discrete , interrupted , crackling , or bubbling sounds that are heard most commonly during inspiration?
Crackles
Setting position ?
Supine position ?
Dorsal position ?
Setting position ? Sitting upright provides full expansion of lungs and provides better visualization of symmetry of upper body parts.
Supine position ? This is the most normally relaxed position . It provides easy access to pulse sites.
Dorsal position ? Position is used for abdominal assessment because it promotes relaxation of abdominal muscles .
Lithotomy position ?
Sims position?
Prone position ?
Lateral position ?
Knee position ?
Lithotomy position ? This position provides maximal exposure of genitalia and facilitates insertion of vaginal speculum .
Sims position? Flexion of hip and knee improves exposure of rectal area and vagina .
Prone position ? Musculoskeletal system
Lateral position ? Heart
Knee position ? Rectum
High-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough
Fine crackles:
Auscultation UNEXPECTED OR ADVENTITIOUS SOUNDS ?
Lower, more moist sound heard during the midstage of inspiration ; not cleared by a cough
Medium crackles:
Auscultation UNEXPECTED OR ADVENTITIOUS SOUNDS ?
1.Just right of the sternum at the second ICS
2.Just left of the sternum at the second ICS
3. Just left of the sternum at the third ICS
4.: Left midclavicular line at the fifth ICS
arotic value
plumonary value
Erbs point
Tricuspid value
Mitral value
