Exam 1 Flashcards
(137 cards)
1
Q
Subjective data
A
What the person says about himself or herself during history taking (symptom, health history)
Cough, shortness of breath
2
Q
Objective data
A
What you as a health professional observe by inspecting, percussing, palpating and auscultating during the physical exam (sign)
3
Q
Source of History
A
Record who furnishes information; judge reliability of informant and how willing he or she is to communicate
Verify all data; you must make the most accurate decision by verifying data first
4
Q
Reason for seeking care
A
Brief spontaneous statement in persons own words describing their reason for visit
Document exact words
Usually involves a description of one or two symptoms and a duration
5
Q
Biographical data
A
Includes name, address, phone number, birth date, age, birthplace, gender, race, occupation, etc. primary language
6
Q
Present health or history of present illness
A
Documented using the eight critical behaviors: Location Character or Quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient's perception
7
Q
Location
A
Be specific; ask the person to point to location
8
Q
Character or quality
A
Specific descriptive terms such as burning, sharp, dull, aching, throbbing
9
Q
Quantity or Severity
A
How bad is the pain; mild, moderate, severe; use the pain scale to quantify pain
10
Q
Timing
A
Onset, duration, frequency; when did symptom first appear?
11
Q
Setting
A
Where was the person; what was the person doing when he symptom started
12
Q
Aggravating or relieving factors
A
What makes pain better or worse; what seems to help
13
Q
Patients perception
A
What do you think is going on; how does it affect daily activities
14
Q
Past Health
A
Childhood illnesses- measles, mumps, chickenpox
Accidents/injuries- auto accidents, fractures, burns
Chronic illnesses- asthma, depression, hypertension,
Hospitalizations- cause, name of hospital, how long, how it was treated
Operations- type of surgery, date, how they recovered
OB history- pregnancies, deliveries
Immunizations- vaccine history
Last exam date- physical, dental, vision, Amy exam
Allergies- allergen and reaction
Current medication-prescription and over the counter
15
Q
Family history
A
Accurate family history highlights diseases and conditions for which a particular patient may be at an increased risk; may seek early screenings
16
Q
Review of systems
A
Assessing objective data; general overall health state; if the patient says yes, stop and access further
Evaluate health promotion practices
17
Q
Functional assessment including activities of daily living (ADLs)
A
How are they doing?; measures a persons self care ability in the areas of general physical health or absence of illness
ADLs- bathing, dressing, eating, toileting, walking
18
Q
CAGE
A
C: cut down Have you ever thought you should cut down your drinking? A: annoyed Have you ever been annoyed by criticism of your drinking? G: guilty Have you ever felt guilty? E: eye opener Do you drink in the morning?
19
Q
Perception of health
A
How do you define health?
What are your concerns?
What are your health goals?
20
Q
Children
A
Caregiver is usually giving the information; nutrition; developmental milestones; how labor and delivery went
21
Q
Adolescent
A
Usually includes sensitive subjects: drugs, sexuality, suicide and depression
Home life, education, job, activities, eating
HEEADSSS- home, education/employment, eating, activities, drugs, sexuality, suicide, safety
22
Q
Older Adult
A
May shrug off symptoms as evidence of growing old; may have chronic problems; may take time to figure out why older person has come for an examination
23
Q
Final Statement
A
Should be the persons reason for seeking care, not your assumption of the problem
24
Q
Obstetric History
A
Recorded as Grav (number of pregnancies), term(reached full term), preterm (premise), Ab(abortion), living
Grav 6 Term 4 Preterm o Ab 2 Living 4
25
Genogram or pedigree
Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members
26
Skin
The body's largest organ system
Waterproof, protective, adaptive, regulates temperature, produces vitamin D
Guards the body from environmental stresses
27
Epidermis
Outer layer; highly differentiated; replaced every 4 weeks
Basal cell layer forms new skin cells
Outer horny cell layer consists of dead keratinized cells
28
Dermis
Inner supportive layer consisting mostly of connective tissue, or collagen; also has elastic tissue that allows the skin to stretch with body movements
29
Subcutaneous Layer
Beneath the epidermis and dermis; layer of adipose tissue
30
Newborn Infants (skin related development considerations)
Lanugo, vernix caseosa, sebum
31
Lanugo
Fine downy hair of a newborn infant
32
Vernix Caseosa
Thick, cheesy substance made up of sebum and shed epithelial cells; will go away with repeated washings
33
Sebum
Holds water in the skin; present in the first few weeks of life, can produce milla which looks like little baby acne
34
Children
Epidermis- thickens, toughens and darkens and the skin becomes better lubricated
Hair- growth accelerates
35
Adolescents
Sweat glands- increase secretions
Subcutaneous fat- deposits increase especially in females
Secondary sex characteristics- begin to develop; breast tissue develops, coarse pubic hair
36
Linea nigra
Change in hormone levels results in increased pigment in the areolae and nipples, vulva, and sometimes in the midline of the abdomen (pregnant women)
37
Chloasma
Discoloration on the face, "mask of pregnancy", can occur in women taking oral contraceptive pills
38
Striae Gravidarum
Stretch marks for pregnancy, develop over abdomen, breast and thighs. Typically fade but never go away
39
Older adults(skin)
Elasticity: loses elasticity, it folds, and says
Sweat and sebaceous glands: decreases, leaves skin dry
Hair matrix: function of melanocytes decreases; hair looks grey and fine
Senile Purpura
40
Senile Purpura
Discoloration, tend to bruise easier, capillaries are more fragile;
41
Melanin
Substance responsible for the various colors and tones of skin in people
Dark skinned people have a genetic advantage in the protection against skin cancer because of melanin. It protects the skin against harmful UV rays. Exposure to UV radiation is the most important risk factor of skin cancer.
42
Pallor
Unhealthy pale appearance, best assessed in nail beds and lips
Black people will be ashen, gray or dull
43
Erythema
Red appearance; intense redness is from excess blood in the dilated superficial capillaries.
44
Cyanosis
Blue appearance; the tissues have high levels of deoxygenated blood
45
Jaundice
Yellowish appearance; increase amounts of bilirubin in the blood
46
Hypothermia
Excessive coolness; temperature lower than expected
47
Hyperthermia
Excessive warmth; temperature higher than normal
48
Diaphoresis
Refers to perfuse sweating that's caused by an increased metabolic rate
49
Dehydration
Loss or removal of water
50
Skin turgor
Indicated of hydration status, notes the skins elasticity
51
Hyperthyroidism
Results in smooth velvety skin
52
Hypothyroidism
Results in rough, dry, flaky skin
53
Thickness
Epidermis is thin over most of the body, although thickened callus areas are normal on palms and soles
54
Edema
Fluid accumulating in the intracellular spaces, this is not normal
55
Peripheral edema
Edema in the feet and hands
56
Dependent edema
Found in areas such as the feet, sacrum of a client bed bound
57
Pitting
Press finger in the area of edema for 2-3 seconds and note depth of indentation
58
Lesions
ABCDE: asymmetry, border, color, diameter, elevation and enlargement; should be described in great detail
59
Macules
Color change seen on skin, flat, less than one centimeter (freckles)
60
Patch
Color change seen on skin greater than one centimeter (Mongolian spots, measles rash)
61
Papules
Skin lesion you can feel, solid, elevated, less than one centimeter (moles, warts)
62
Plaques
Papules form a mass, wider than one centimeter(psoriasis)
63
Nodules
Skin lesion, solid, can be hard or soft, larger than 1 centimeter
64
Tumor
Digs deeper into the chest, benign or malignant
65
Wheals
Transient(come and go) and red raise in the skin, irregular shape (mosquito bite, allergic reaction)
66
Urticaria (hives)
Multiple wheals come together to form this, severe itching
67
Vesicles
Elevated cavity that contains fluids, also known as blister(herpes)
68
Bullas
Larger than one centimeter (contact blisters, burns)
69
Cysts
Fluid filled cavity, located in dermis and subcutaneous layer, elevates skin (sebaceous cyst)
70
Pustules
Pus in the cavity, round and elevated (acne)
71
Vestigial
Hair for humans is no longer needed for protection from cold and skin trauma
72
Eccrine glands
Coiled tubules that open directly onto the skin surface and produce sweat; no odor
73
Apocrine glands
Produce a thick, milky secretion, and open into the hair follicles; create a musky odor
74
Xerosis
Dryness of the skin
75
Seborrhea
Oily of the skin
76
Pruritus
Severe itching of the skin
77
Alopecia
Hair loss
78
Sulfonamides, thiazides, diuretics, oral hypoglycemic agents, and tetracycline
Drugs that increase sunlight and give a burn response
79
Vitiligo
The complete absence of melanin pigment in patchy areas of white or light skin
80
Senile angiomas
Small, smooth, slightly raised bright red dots that commonly appear on the trunk
81
Lichenification
Results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules
82
Trichotillomania
Self induced hair loss
83
Pleurae
Visceral pleura lines outside of lungs
Parietal pleura lines inside of chest wall and diaphragm
Pleural cavity is potential space filled only with few millimeters of lubricating fluid
84
Trachea and Bronchi
Transport gases between the environment and lungs
Make dead space: space that is filled with air but is not available for gaseous exchange
85
Bronchial tree
Protects alveoli from inhaled foreign particles
86
Bronchi
Lined with cells that secrete mucus to trap foreign particles
87
Gas exchange
Occurs across respiratory membrane in alveolar duct and in millions of alveoli
88
Vertebra prominens
Spinous process of C7
89
Skeletal deformities
Barrel chest, kyphosis, scoliosis
90
Barrel Chest
Characterized by a rounded appearance, horizontal ribs, slight kyphosis; the chest appears in constant inspiration; associated with normal aging, and infants chest, and with chronic emphysema and asthma
COPD
91
Kyphosis
Humpback; exaggerated posterior curvature of the thoracic spine. Causes significant back pain and limited mobility. Associated with aging, especially in women. Related to physical fitness
92
Scoliosis
Lateral S-shaped curvature of the thoracic and lumbar spine.
93
Lordosis
Exaggerated curvature of the lumbar vertebrae
94
Upper airway
Nasopharynx(nose), oropharynx(mouth), laryngopharynx, larynx
95
Lower airway
Trachea, bronchi, bronchioles, and alveoli
96
Lungs
Right lung: 3 lobes, upper middle and lower, shorter
Left lung: 2 lobes, upper and lower, narrower
97
Tripod position
Leaning forward with arms braced against their knees, chair, or bed. Gives them leverage so the abdominal, intercostal, and neck muscles all can aid in expiration
98
Hypoxia
Depletion of oxygen
99
Tachypnea
Rapid, shallow breathing, with an increased rate greater than 24 per minute
Causes: normal response to fear, exercise, and fever
Also occurs with pain, pneumonia, pleurisy, alkalosis, and lesions in the pons.
100
Bradypnea
Slow breathing; decreased but regular rate of less than 10 per minute.
Causes: can occur with drug induced depression of the respiratory center in the medulla, increased intracranial pressure and diabetic coma.
101
Apnea
Total absence of breathing; may be periodic
102
Hyperpnea
Increased depth of respirations; can occur during strenuous exercise and diabetic ketoacidosis
103
Hyperventilation
An increase in both rate and depth of inspirations
Causes: exertion, fear, or anxiety; seen in many acidotic states.
104
Hypoventilation
Irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain
105
Cheyne-Stokes
Cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth, then decreasing. The breathing cycle lasts 30-45 seconds, with periods of apnea alternating the cycle.
Causes: severe heart failure (most common), renal failure, meningitis, drug overdose
Occurs normally in infants and aging persons duri sleep
106
Biots
Similar to cheyne stokes, but the pattern is irregular. Lasting anywhere from 10 seconds-1 minute.
Causes: seen with spinal meningitis, heat stroke, head trauma, brain abscess, encephalitis
107
Kussmaul's
Panting labored kind of respiration with increased rate and depth. Associated with severe metabolic acidosis and renal failure.
108
Ribs
Inserted to the spine at about a 45 degree angle
May be increased on a person with emphysema
109
Costal angle
Should be less than or equal to 90 degrees
110
Accessory muscles
Include sternocleidomastoid, trapezius, and abdominal muscles
111
Anterior Thoracic Landmarks
Suprasternal notch, sternum(breast bone), angle of Louis, costal angle
112
Suprasternal notch
Hollow ushaped depression just above the sternum, between the clavicles.
113
Sternum
The "breastbone", three parts: manubrium, body, xiphoid process
114
Sternal angle
Also called angle of Louis; articulation of the manubrium and body of the sternum, and it is continuous with the second rib
Marks the site of tracheal bifurcation into the right and left main bronchi.
115
Posterior Thoracic Landmarks
Vertebra prominens, spinous processes, inferior border of the scapula, twelfth rib
116
Reference lines anterior chest
Midsternal, midclavicular
117
Lateral reference lines
Anterior axillary line, posterior axillary line, midaxillary line
118
Deep inspiration
Lung expansion, lungs have lower border level, will drop to t12 vertebra
119
Hypoxemia
Decrease of oxygen in the body
120
Hypercapnia
Increase of carbon dioxide in the blood
121
Pectus carinatum
Sternum protruding forward; results in increase AP diameter
122
Anteroposterior to lateral diameter
Ratio of 1:2
In older adults, you will observe an increase in the AP diameter which is normal
123
Sinus Tracts
Narrow openings or passageways underneath the skin that results in dead space with potential for abscess formation
124
Crepitus
A coarse, crackling sensation palpable over the skin surface that indicates air has escaped from the lung and enters the subcutaneous tissue of the chest
May be present in emphysema, pneumothorax, open thoracic injury, or thoracic surgery
125
Primary muscles of respiration
Diaphragm and intercostals
126
Respiratory excursion
Performed to access range and symmetry of respiratory movement
127
Tactile fremitus
Strongest between the scapula and around the sternum because this is where the major bronchi are closest to the chest wall; normally decreases progress downwards; feels greater over a thin chest wall than over an obese or heavily muscular one
Palpable vibration
128
Increased fremitus
Occurs with compression or consolidation of lung tissue; may be due to a mass, pneumonia, or other inflammatory processes
129
Decreased fremitus
Occurs when anything obstructs the vibration; may be due to an obstructed bronchus, pleural thickening, pleural effusion, pnuemothorax, emphysema
130
Percuss
Gently tap; normal lung should be air filled, producing a resonance sound that is loud intensity and low pitched.
131
Dull percussion
Abnormal density in the lung; lung tumor, pneumonia, pleural effusion and atelectasis will cause
132
Hyperresonant
Too much air is present; caused by emphysema and pneumothorax
133
Diaphragmatic excursion
Movement of the diaphragm as it descends on inspiration and rises on expiration
134
Vesicular Breath sounds
Soft, low pitched rustling sounds located over the periphery of the lung; most predominant breath sounds; if decreased over the periphery, this may indicate pneumonia, emphysema, pleural effusion, or atelectasis.
135
Bronchial or tracheal breath sounds
Loud, high pitched tubular sounds over the trachea and major bronchi; if auscultated over periphery, it may indicate consolidation or atelectasis
136
Bronchovesicular breath sounds
Moderately pitched breath sounds located between the scapulae posteriorly and in either side of the sternum at the first and second intercostal space anteriorly. If heard over periphery, it may indicated consolidation.
Expected near major airways
137
Inaudible breath sounds
May indicate atelectasis or pneumothorax
