exam 3 Flashcards
musculoskeletal assmnt mobility assmnt integumentary assmnt neuro assmnt HEENT assmnt genital/repro assmnt sterile gloving wound care drains medication calc non-parenteral medications
1
Q
what are the compnenets of the musculoskeletal system?
3
A
bones
joints
muscles
2
Q
what is the normal function of the musculoskeletal system?
4
A
alignment
posture
balance
coordinated mvmnt
3
Q
what is full ROM?
A
ability to move all joints through full extent of intended function
4
Q
what is passive ROM?
A
someone else moves the joint
5
Q
what is active ROM?
A
the patinet moves a joint through normal ROM
6
Q
what is a normal gait?
A
requires strong leg muscles
extension and flexion of legs
controlled center of gravity
neuromuscular ability
7
Q
what is atrophy?
A
decreased muscle size from disues
8
Q
what is strength?
A
strong and equal bilaterally
9
Q
what is flaccidity?
A
decreased muscle tone
cerebral palsy
10
Q
what is spasticity?
A
increased muscle tone from neurological impairment
parkinson’s
11
Q
lifespan considerations
musculoskeletal: newborn and infant considerations
2
A
- newborn mvmnt is random and reflexive
- control increases as neuro sys matures
12
Q
lifespan considerations
musculoskeletal: toddler and preschooler considerations
2
A
- refinement of gross and motor mvmt ( 1- 5 yr)
- coorination continues to develop
13
Q
lifespan considerations
musculoskeletal: child and adolescent considerations
2
A
- continued refinement of gross and fine motor
- screen for **scoliosis **
14
Q
lifespan considerations
musculoskeletal: adolescent considerations
2
A
- need physical activity to build enough muscle and coordination
- rapid growth
15
Q
lifespan considerations
musculoskeletal: adult and older adults considerations
A
- work can cause alteration
- middle age (40 - 60 yr): muscle tone, density and mass decrease
- aging: postural changes, chronic joint disorders, center of gravity, screen for kyphosis and scoliosis
16
Q
lifespan considerations
kyphosis is common in older ____ due to _________
A
women
osteoporosis
17
Q
lifespan considerations
lordosis is seen with ____ to compensate with the shift of _____
A
pregnancy
gravity
18
Q
subjective assessment of musculoskeletal
muscles
A
pain?
cramping?
weakness (with mvmnt)?
19
Q
subjective assessment of musculoskeletal
bones
A
pain?
deformity?
accidents?
stiffness?
20
Q
subjective assessment of musculoskeletal
joints
A
creptius
pain
deformity
21
Q
subjective assessment of musculoskeletal
functional assessment
A
ADL limitations:
eating/drinking
toileting
bathing/dressing
22
Q
subjective assessment of musculoskeletal
self care behaviors
A
pain with EXERCISE
weight gain/loss
23
Q
objective assessment of musculoskeletal
inspection
4
A
size: may need to measure
contour
swelling
color
24
Q
objective assessment of musculoskeletal
palpation
6
A
heat
swelling
mass
tender
crepitus
tone
25
# objective assessment of musculoskeletal
ROM
## Footnote
3
ask for active
if not, gently attempt passive
test muslce strength (apply opposing force)
26
how do you test strength of muscle?
apply an opposing force
27
# ROM
upper body
shoulders
elbows
wrists
hands
28
# ROM
lower body
hips
knees
ankles
feet
29
# ROM
entire spine
norma curves: convex thoracic and concave lumbar
kyphosis, lordosis, or scoliosis
30
# ROM
assess gait
normal is coordinated and smooth or fluid and balanced
walk on tiptoes, "drunk test"
31
muscle strength
0
1
2
3
4
5
## Footnote
grade 0 to 5
0: **no** muscle contraction
1: **trace contraction** of m. (10% m. strength)
2: moves m. when **gravity is eliminated** (passive ROM and 25% m. strength)
3: moves m. **against gravity** (50% m strength)
4: moves m group **against resistance** from eaminer (75%)
5: moves muscle to **overcome** examiner's full resistance (100% strength)
32
# musculoskeletal
teaching topics
exercise and physical acitivty
posture and ergonomics
nutrition (joint/bone health) (vit D, Ca, H2O)
injury prevention + management
33
# musculoskeletal
what is scoliosis?
sideways curvature of the spine
dx with adolescents
34
what is lordosis?
exaggerated inward rounding of the cervical or lumbar spine
35
what is kyphosis?
exaggerated forward curivng of the spine
36
# molbility
crutch walking up stairs
good foot to heaven
bad foot to hell
keep one crutch with each foot
37
# mobility
cane walking
hold the cane on the strong side
cane will move forward when the weaker side moves foward
COAL (cane opposite affected side)
38
# mobility
walking with a walker
WWAL (walker w affected leg)
39
# mbolity
supine
pt flat on back
(indicators: general exam, post lumbar puncture)
40
# mobility
high fowlers position
head of bed elevated @ 90
Indicated: NGT placement, SOB
41
# mobility
prone position
lying in the abdomen with head turned to one side
Indicator: spina bifida, drainage of secretions, may help with oxygenation
42
# mobility
tripod position
pt is a sitting position and leaning forward
indicators: maximum lung expansion
43
# molbility
sims position
pt laying on **left** side, hip, and lower extremity is straight with right knee and hip bent
indicator (enema/suppositiories )
44
When fitting crutches, the nurse ensures the top of the crutch is:
Crutches should be 2–3 finger-widths below the armpit to avoid nerve damage (brachial plexus injury)
45
# mobility
semi-fowlers position
HOB elevated 30 - 45 degress
indicator: head injury
46
# mobility
trendelenburg postion
HOB is low
FOB is raised
indicator: hypotensive
47
What is a safety teaching for walker use?
elbows should be slightly flexed (~15–30°)
48
For a non–weight-bearing right leg, what crutch gait is appropriate?
Three-point gait: both crutches and the affected leg (non–weight-bearing) move together, then the strong leg follows.
49
Which gait should be used for a client who can bear weight on both legs but has poor coordination?
Four-point gait is safest for poor balance/coordination because it mimics normal walking.
50
A nurse is teaching a client to use a walker. Which of the following instructions is appropriate?
Move the walker, then step with the weak leg, followed by the strong leg.
Walker → weak leg → strong leg. This ensures stability.
51
When going down stairs on crutches, the correct order is:
Crutches → weak leg → strong leg
crutches first, then bad leg, then good leg. “Down with the bad.”
52
# skin assessment
components of integumentary assessment
skin
hair
nails
53
# integumentary system
normal findings of skin assesement
color:
texture:
temp:
mositure:
turgor:
hair:
nails:
lesions:
color: pink/appropriate for ethnicity
texture: smooth and soft
temp: warm
mositure: dry
turgor: no tenting, recoil
hair: even distribution
nails: pink and smooth
lesions: freckles, moles
54
# integumentary system
abnormal findings of skin assesement
color:
texture:
temp:
mositure:
turgor:
hair:
nails:
lesions:
color: blue, yellow, red
texture: rough, not intact
temp: cold or hot
mositure: sweaty
turgor: tenting
hair: loss (alopecia) or excess gain (hiritusim)
nails: thick (clubbing)
lesions: rash, drains, brusies
55
# integumentary system
abnormal color findings
## Footnote
3
blue: cyanotic (poor O2)
red: erythema/hot/rash
yellow: jaundice (liver!)
56
# developmental considerations
integumentary system: newborns/infants
## Footnote
3
mangolian spots
nevus simplex
vernix caseosa
57
# developmental considerations
integumentary system: kids + adolescents
## Footnote
4
candidness
acne
impetgo
eczema
58
integumentary system: adults
## Footnote
3
straie
linea nigra
senile lentigines/liver spots
59
# integumentary system
what are mongolian spots?
darker pigmentation spot right above butt
common in: af am, nativa am, asain
monitor fades with age
60
# integumentary system
what is nevus simplex?
* "stork bite"
* red/pink patch @ hairline, back of neck, btwn eyes
* collection of capillary vessels near skin
* away with time = 6 months
61
# integumentary system
what is vernix caseosa?
* whitish cream covers fetus's skin to protect skin from last tri to birth
* delay 1st bath up to 24 hr prevent infection
62
# integumentary system
what is candidness?
* "thrush", yeast infection
* white covering on tongue
* caused by meds and treated with anti-fungal
63
# integumentary system
what is impetigo?
* red sores (that ooze yellow) around nose/mouth
* highly contagious
* treated with AB
64
# integumentary system
what is eczema?
* red clusters/hive like anywhere on body
* long lasting chronic inflammation
* cause: unkown
* Tx w steroid cream
65
# integumentary system
what is a linea nigra?
* darkened line through belly button
* common in 2nd tri
* caused by hormones
* most commin in white ppl
66
# integumentary system
what is straie?
* purple/pink/white lines (stomach)
* d/t rapid growth/weight gain
* 2nd sem: red to silver/white
67
# integumentary system
what are senia lentigens?
| liver spots
* small black/brown spots (hands)
* age-related common on spots that are exposed to sun
68
# subjective assessment: integumentary
1. past ____ skin diesase
2. change in ____ and _ and ___
3. _______ dryness or moisture
4. ____________ (itching)
5. ____________ (ecchymosis)
6. lesion or ______
7. hair ____
8. environment/___________ hazards
history
moles or pigmentation
excessive
puritus
brusing
rash
loss
occupational
69
# objective assessment: integumentary
skin: inspect and palpate
color/temp/mosture/texture?
integrity?
edema?
turgor?
mobility?
acitve bleeding?
70
# objective assessment: integumentary
hair: inspect and palpate
color/texture?
distribtuion?
lesions?
lice?
71
# objective assessment: integumentary
nails: inspect and palpate
shape? apex
angle? 160
contour?
color?
clubbing?
cap refill?
72
# teaching topic: integumentary
ABCDEF of moles
asymmetry: round?
border: defined or jagged?
color: 1+ color?
diameter: 6 mm+ (pencil eraser)
evolving: thicker? color change? bigger?
funny looking:
73
# diagnostic tests: integumentary
biopsy
extraction of sample cells/tissues for examination to determine the presence/extent of a disease
74
# diagnostic tests: integumentary
wound specimen
sample of the fluid or tissue from a wound
75
What is skin turgor, and what does poor turgor indicate?
* Skin turgor assesses hydration by pinching skin.
* Poor turgor (tenting) suggests dehydration or aging (↓ elasticity).
76
What is the Braden Scale, and why is it used?
* Tool to predict pressure injury risk
* Assesses: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction & Shear
* Score range: Lower = higher risk
77
What are signs of poor perfusion seen in skin assessment?
* Pallor, cyanosis, cool temperature, delayed capillary refill (>2 sec)
* Especially concerning in fingers, toes, lips, and nailbeds
78
What is clubbing of the nails and what does it indicate?
Clubbing = bulbous fingertips with curved nails
Suggests chronic hypoxia, often due to lung or heart disease
79
How do pressure ulcers typically present?
Non-blanchable redness (Stage 1)
Partial-thickness skin loss (Stage 2)
Full-thickness with fat visible (Stage 3)
Exposed bone/tendon (Stage 4)
Document size, location, drainage, odor, and tissue type
80
What integumentary change is common with aging?
Thinning skin
Decreased elasticity
Decreased sweat and oil production
Increased bruising
Slower wound healing
81
# neuro subjective assessment
headache
## Footnote
8
now or hx?
sign of ICP
where?
describe?
when?
onset?
associated w something?
severe: stroke or htn crisis
82
# neuro subjective assessment
head injury
## Footnote
3
TBI/trauma
LOC?
when?
83
# neuro subjective assessment
dizziness:
vertigo:
dizziness: lightheaded or pt spinning
vertigo: world is spinning/ swimming sensation
84
# neuro subjective assessment
seizures
what type?
genetic or random?
convulsions?
how long did it last?
when?
when was your last one?
85
# neuro subjective assessment
12 ASPECTS OF NEURO ASSESSMENT (ask about)
headache
head injury
dizziness/vertigo
seizures
tremors
weakness
incoordination
numbness/tingling
difficulty swallowing
diffciutly speaking
patient-centered care
environmental/occupational hazards
86
# neuro subjective assessment
incoordination
issues w balance
stroke?
normal?
older adults: memory issues or vision changes
87
# neuro subjective assessment
patient centered care
## Footnote
4
spinal cord injury?
past hx of stroke?
meningitis?
congenital defects?
88
# neuro subjective assessment
premature babies
at risk for neuro delays/changes
pre-eclampsia or gestational diabetes
89
# neuro assessment
what are the 5 aspects of neuro and mental status exam?
mental status
cranial nerves
motor function
sensation
reflexes
90
# neuro assessment
mental status
## Footnote
AOx ...
person: name/DOB
orientation: where are you?
time: year/day?
situation: why are you here?
91
# neuro assessment
unconcious pt: how do assess
## Footnote
6
call out name
light touch
loud voice
shaking/ hard touch
painful stimuli (pen on nail bed or pinch)
concerned!
92
# neuro objective assessment
motor function
finger to nose
gait
ROM/strength
romberg: "drunk test"
93
# neuro objective assessment
sensation
sharp vs dull (tongue blade)
pain and sensation
94
# neuro objective assessment
reflexes
reflex hammer with deep tendons:
patellar, biceps, achilles
95
# GCS
GCS: eye response
## Footnote
4
4: spontaneous
3: to speech
2: to pain
1: no repsonse
96
# GCS
GCS: motor response
## Footnote
6
6: obeys command
5: localizes pain
4: flexion - withdrawl
3: flexion - abnormal (decorticate posturing)
2: extension - abormal (decebrate posturing)
1: no reponse
97
# GCS
GCS: verbal response
## Footnote
5
5: correct response to ? (2025)
4: confused conversation (1962)
3: inappropriate speech (after lunch)
2: incomprehensible speech (sajdfjs)
1: no reponse
## Footnote
what year is it?
98
# GCS
EVM
456
99
# GCS
what is the possible range for a GCS score?
3 - 15
less than 8: coma/severe impairment
100
# neuro objective assessment
PERRLA
pupils
equal
round
react to
light and
accomodation
101
# neuro objective assessment: PERRLA
what size should pupils be?
3 to 4 mm and equal
102
# neuro objective assessment: PERRLA
when light is shined in eyes, what happens to pupils?
constrict
103
# neuro objective assessment: PERRLA
in a dark room, pupils ______
dilate
104
# neuro objective assessment: PERRLA
what does accomodation mean?
The eye's ability to change focus from near to far objects
105
# neuro objective assessment: PERRLA
As you focus on a near object, the pupils should _______
constrict
106
# neuro objective assessment: PERRLA
what is ansiocoria?
unequal pupil sizes
(may be genetic or trauma/meds/surgery/etc)
107
# neuro objective assessment: PERRLA
an aneurysm causes __________ pupils
dilated
108
# neuro objective assessment: PERRLA
what causes: Mydriasis (Dilated)
| "Flight or Fright"
Stimulants, Anticholinergics, Hallucinogens
109
# neuro objective assessment: PERRLA
what causes: Miosis (Constricted)
| "Rest and Digest"
Opioids (pinpoint!)
Cholinergics
Sedatives
110
# neuro objective assessment: PERRLA
cause of unilateral dilation
CN III compression
111
# neuro objective assessment: PERRLA
fixed bilateral dilation
injury to midbrain
dangerous!
112
# neuro objective assessment: PERRLA
how should pupils react?
| speed
abnormal: slow/sluggish
normal: quick
113
What are expected pediatric reflexes that disappear with age?
Moro (startle): gone by 4–6 months
Rooting: gone by 4 months
Palmar grasp: gone by 5–6 months
Tonic neck (fencer's reflex): gone by 5–7 months
Babinski: normal until 1 year (toes fan out); abnormal after 2 years
114
What is decorticate posturing and what does it indicate?
Flexion of arms toward the core
Indicates damage to cerebral hemispheres
More favorable than decerebrate
115
What is decerebrate posturing and what does it indicate?
Arms extended and internally rotated
Indicates brainstem damage
Worse prognosis than decorticate
116
# neuro objective assessment
CN I: _____
Function? Injury? Test?
Olfactory
Function: Smell (sensory)
Injury: Loss of smell (anosmia)
Test: **Identify familiar odors** with each nostril
117
# neuro objective assessment
CN II: ____
Function? Injury? Test?
optic
Function: Vision (sensory)
Injury: Visual field loss, blindness
Test: **Snellen chart**: Visual acuity and visual fields
118
# neuro objective assessment
CN III: ____
Function? Injury? Test?
Oculomotor
Function: Eye movement (up/down/medial), pupil constriction, eyelid elevation (motor)
Injury: Ptosis, diplopia, dilated pupil, impaired eye movement
Test: PERRLA (**follow the moving finger**), extraocular movements
| combined with 4 and 5 with cardinal gaze
119
# neuro objective assessment
CN IV: _____
Function? Injury? Test?
trochlear
Function: Eye movement – superior oblique muscle (motor)
Injury: Difficulty looking down/in (vertical diplopia)
Test: Have pt look **down and in** (toward nose)
120
# neuro objective assessment
CN V: ____
Function? Injury? Test?
trigeminal
Function: Facial sensation (ophthalmic, maxillary, mandibular); chewing (motor)
Injury: Loss of facial sensation, weak mastication
Test: **Light touch (facial sensation) AND jaw clench (jaw mvmnt)**
121
# neuro objective assessment
CN VI: _____
Function? Injury? Test?
Abducens
Function: Lateral eye movement – lateral rectus muscle (motor)
Injury: Eye cannot abduct; medial strabismus (eye drifts inward)
Test: **Ask pt to look side to side** (lateral)
122
# neuro objective assessment
CN VII: ____
Function? Injury? Test?
Facial
Function: Facial expressions (motor), taste anterior 2/3 tongue (sensory), lacrimal/salivary glands
Injury: Facial droop, Bell’s palsy, loss of taste
Test: **Smile, frown, raise eyebrows**, taste test (sweet/salty)
123
# neuro objective assessment
CN VIII: ________
Function? Injury? Test?
vestibulocochlear
Function: Hearing and balance (sensory)
Injury: Hearing loss, vertigo, balance issues
Test: **Whisper test** (Romberg)
124
# neuro objective assessment
CN IX: ________
Function? Injury? Test?
glossopharyngeal
Function: Swallowing, taste posterior 1/3 of tongue, gag reflex (mixed)
Injury: Impaired gag/swallow, loss of taste, dysphagia
Test: Gag reflex, **swallow, taste** (bitter/sour)
125
# neuro objective assessment
CN X: ________
Function? Injury? Test?
vagus
Function: Swallowing, speech, parasympathetic control of thorax/abdomen
Injury: Hoarseness, dysphagia, loss of gag reflex, decreased GI motility
Test: **Say “Ah”—uvula should rise midline, listen to voice** (hoarsness)
126
# neuro objective assessment
CN XI: ________
Function? Injury? Test?
Spinal Accessory
Function: Shoulder shrug, head turn (motor to SCM & trapezius)
Injury: Weakness turning head or lifting shoulders
Test: **Shrug shoulders, turn head** against resistance
127
# neuro objective assessment
CN XII: __________
Function? Injury? Test?
Hypoglossal
Function: Tongue movement (motor)
Injury: Tongue deviates to injured side, difficulty speaking/swallowing
Test: **Stick out tongue and move side to side** (should be midline), speak (“light, tight, dynamite”)
128
# CN
CN Mnemonic
## Footnote
2
Some say marry money but my brother says that brains matter more
Oh, Once one takes the anatomy final very good vacations are heavenly
129
# stroke
causes of stroke
Htn
atherosclerosis
smoking
obesity
130
# stroke
S/S of stroke
facial drooping
arm weakness
speech difficulty
131
# infant reflexes
Rooting Reflex
How to Elicit: Stroke the infant’s cheek or corner of mouth
Normal Response: Infant turns head toward stimulus and opens mouth
duration: birth --> 3 to 4 months
132
# infant reflexes
Sucking Reflex
How to Elicit: Place a gloved finger or nipple in infant’s mouth
Normal Response: Infant sucks rhythmically
duration: birth --> 3 to 4 months
133
# infant reflexes
Moro Reflex (Startle Reflex)
How to Elicit: Let the infant’s head drop slightly or make a sudden loud noise
Normal Response: Arms extend and abduct, hands open, then arms flex and close
Duration: Around 4–6 months
134
# infant reflexes
Palmar Grasp Reflex
How to Elicit: Place a finger in the infant’s palm
Normal Response: Infant grasps finger tightly
Disappears: Around 3–4 months
135
# infant reflexes
Plantar Grasp Reflex
How to Elicit: Press a finger against the sole of the foot
Normal Response: Toes curl downward
Duration: birth --> 8–10 months
136
# infant reflexes
Babinski Reflex
How to Elicit: Stroke sole of the foot from heel to toe
Normal Response: Toes fan out and big toe dorsiflexes
Duration: birth ---> 12 to 24 months (If persists → neurological concern)
| positive (fan out) in adult is abnromal!
137
# infant reflexes
tonic-clonic reflex
| fencer position
How to Elicit: Turn the infant’s head to one side
Normal Response: Arm on that side extends, opposite arm flexes
Disappears: 2 mnths to 6 mnths
138
# HEENT
head/face: subjective
determine pt history (headache, head injury, dizziness, surgery
139
# HEENT
head/face: objective
## Footnote
4
skull/scap: normocephalic or micro/macro?
TMJ: grating/clicking?
skin: masses or bruising
facial expression/structures
140
# HEENT
head exam
normal:
abnormal:
peds:
Normal: Normocephalic, atraumatic
Abnormal: Microcephaly, macrocephaly, asymmetry, bulging fontanels (↑ ICP)
Peds: Posterior fontanel closes by 2 months; anterior by 12–18 months
141
# HEENT
developmental considerations: pediatrics
## Footnote
5
* measure head circumfrence in cm
* every visit untill 2 yr
* yearly until 6 yr
* gain head control/posture by 4 months
* tonic neck reflex
142
# HEENT peds
bulging fontanel:
indented fontanel:
b: high ICP (w crying)
I: dehydrated/malnutrition
143
# HEENT
eyes: subjective
## Footnote
5
vision changes
pain
redness
discharge
glasses/contacts
144
# HEENT
eyes: objective
snellen chart
tumbling E
near vision
confrontation test
145
# HEENT: eyes
tumbling E is used for
non-native speakers
kids
cognitive issues
illiterate
146
# HEENT: eyes
parameters for snellen chart
20 ft away, well lit
top # is pt distance from chart
bottom # is what normal ppl can see
## Footnote
20/40 means @ 20 ft away the pt can see what a normal person can see at 40 ft
147
# HEENT
eyes assessment
normal:
abnormal:
peds:
Assessment: Inspect conjunctiva, sclera; test PERRLA, EOMs
Normal: Sclera white, conjunctiva pink and moist, PERRLA, full EOMs
Abnormal: Redness, jaundice, discharge, unequal pupils, nystagmus
Peds: May have transient strabismus (crossed eyes) until 3 months old
148
# HEENT: eyes
inspect external eye
eyebrows
eyelids and lashes
eyeballs
conjuntiva
sclera (pink/yellow)
149
# HEENT: eyes
ophthalmoscope exam: RED REFLEX
## Footnote
6 steps
1. have scope set to the widest circle, white light
2. darken room
3. bring light from the side
4. find the light on the patient's face then bring in the light until you see the red/organe glow
5. don't turn the dials
6. record as red-light reflex present bilaterally
150
# HEENT: eye
pediatric considerations: eyes
poor eye muscle __________
coordination
151
# HEENT
pediatric considerations: eyes
can fixate on object at ____ months
3 to 4
152
# HEENT
pediatric considerations: eyes
most are born ____________ which gradually improves by age ...
farsighted
7 to 8
153
# HEENT
subjective assessment: ear
pain
discharge
hearing loss
tinnitus
Hx of ear infections
154
# HEENT
objective assessment: ear
inspect external ear: size, shape, skin color
inspect internal ear: tympanic membrane
155
# HEENT: ears
otoscope exam
2 sizes for covers
look towards nose (don't go too deep)
adult: pull pinna UP and BACK
peds (under 3): pull pinna straight DOWN
156
# HEENT: ear
tympanic membrane assessment
NORMAL
color: shiny, translucent, pearly gray
light reflex: present
intact
ABNORMAL
color: red, bulging (otitis media)
light reflex: absent
holes/perforated
157
# HEENT: ears
hearing acuity is tested 3 ways:
audiometer testing: range of frequencies
whisper test: 3 syllables, pt repeat back, high frq
romberg test: balance/drunk test
158
# HEENT
Developmental Highlight
Infant Vision Milestones:
Blinks to light by birth
Tracks objects by 2 months
Smiles responsively by 6 weeks
Fixes and follows by 3 months
159
# HEENT: ears
developmental considerations for infants and children
ear canal is shorter and straighter
* inc risk of ear infections
* encourage breastfeeding
* don't prop bottle or use in bed
* stop smoking (caregivers)
* more common in males
160
# HEENT
nose: external inspection
skin
symmetrical
midline
no deformities
161
# HEENT
nose: internal inspection
mucosa
discharge
(epitaxis: blood or rhinorrhea: CSF/drainage)
162
# HEENT
nose assessment
normal:
abnormal:
peds:
Assessment: Inspect for symmetry, patency, septum position
Normal: Midline septum, nares patent, no drainage
Abnormal: Deviated septum, flaring (sign of respiratory distress), thick drainage
Peds: Infants are obligate nose breathers until 4–6 weeks
163
# HEENT
nose inspection:
sinuses
septum
sinus: use thumbs, frontal + maxillary
septum: midline, intact, deviated?
164
# HEENT
neck assessment
## Footnote
5
skin changes
erythema
scars - thyroidectomy
masses (goiter) or lymph node enlargment
lumps or swelling
165
# HEENT
throat assessment
## Footnote
4
ROM
Trachea: feel notch/symmetry
thyroid: not palpable
lymph nodes: size, location, shape, mobility, tenderness
166
# HEENT
inspect and palpate: posterior pharynx
hard palate
* pink/moist, intact
* no exudate
* uvula and soft palate rise with midline with "ah"
167
# HEENT
tonsils: normal
## Footnote
4
pink
no exudate
grade +1 to +4
0 is surgically absent
168
# HEENT
throat/mouth assessment
normal:
abnormal:
peds:
Assessment: Inspect lips, oral mucosa, tongue, tonsils, uvula
Normal: Pink, moist mucosa; midline uvula; tonsils 1+ or 2+
Abnormal: White patches (thrush), exudate, 3+/4+ tonsils (infection or obstruction)
Peds: Epstein pearls may be present in newborns; tooth eruption starts ~6 months
169
# HEENT
neck assessment
normal:
abnormal:
peds:
Assessment: Inspect for symmetry, ROM; palpate lymph nodes, trachea, thyroid
Normal: Midline trachea, full ROM, non-palpable thyroid, small mobile nodes
Abnormal: Tracheal deviation, stiff neck (meningitis), enlarged tender nodes
Peds: Head lag normal until ~4 months; check for torticollis
170
# reproductive
subjective data: breast
## Footnote
10
1. pain (onset, location, hormones)
1. lumps/thickening (where, onset?)
1. discharge (color, bilat, smell, thickness, onset?)
1. rash (onset, where?)
1. swelling (where, onset, hormones?)
1. trauma (break in skin)
1. Hx of breast disease
1. surgeries (age, reduction, enhancement, masectomy?)
1. medications (oral contraceptives)
1. patient centered care: own BSE?
171
# reproductive
objective: breast inspection
general appearance: (L > R size)
skin: even, edema?
nipple: midline, inverted, protruding?
172
# reproductive
objective: breast palpation
breast self exam
1. press the 3 middle fingers in a circular motion
2. use 3 levels of pressure (light, deep, deeper)
3. follow an up and down pattern
## Footnote
do in shower or tub or lying flat on back
after period: boobs are smallest
173
# reproductive
female subjective data for genitourinary system
## Footnote
9
1. LMP (clots, flow, PMS S/S, 1st day of last cycle?)
1. obstetric Hx (when, complications, #, abortion?)
1. menopause (1 yr w/o cycle)
1. pain
1. urination (urgency, burning, incontinent?)
1. vaginal discharge (thick and odorous?)
1. history (surgery?)
1. sexual activity (M or F? more than 1?)
1. STIs (known contact with STI?)
174
# reproductive
male subjective data for genitourinary system
## Footnote
7
1. pain
1. urination (diff w stream, dribbling)
1. penis
1. scrotum (lump, swelling, size, bulging?)
1. history
1. sexual activity
1. STI
175
# reproductive
female genitalia: inspection and palpation
color
lesions
hair distribution
discharge
## Footnote
pair w care (up to bathroom), not routine unless concern
176
# reproductive
dx: pap smear
less than 21: none
21 - 29 yo: every 3yr
30 - 65 yo: w/o HPV test = 3 yr // w HPV = 5 yr
65 + yo: none
exceptions: abnormal results, HPV vax, post hysterectomy
177
# reproductive
male genitalia: inspection and palpation
penis (uncircumzied? wrinkled and hairless)
urethral meatus
scrotum (L lower than R)
testis (oval, firm, rubbery, smooth, same size)
hernia: out pocket of tisue
inguinal lymph nodes
prostate (Dr do, BPH enlarged
178
# reproductive
objective data: testicular self exam
TSE
start at 13/14 for life
once a month
do it in the warm shower
examine and report changes
179
# reproductive
TSE steps
1. cup one testicle at a time using both hands (warm shower)
2. examine by rolling the testicle btwn thumb and fingers (slight pressure)
3. examine spermatic cord and epididymis (tube like structures that connect on the back side of each testicle)
4. feel for lumps, change in size or irregularities (normal for one to be slightly larger than the other)
180
# reproductive
What are normal findings during an external female genital exam?
Symmetric labia, no lesions or masses, even pubic hair distribution, no abnormal discharge.
181
At what age should females begin getting Pap smears, and how often if normal?
Begin at age 21; every 3 years if results are normal
182
What are normal testicular findings in a male reproductive exam?
Testes smooth, equal in size, firm, freely movable, no masses or tenderness
183
What are signs of a possible inguinal hernia during exam?
Bulging in the inguinal region when the patient bears down or coughs.
184
What are abnormal findings during a breast exam?
Lumps, nipple retraction, discharge (especially bloody), skin dimpling or peau d’orange.
185
# sterile gloving
what is medical asepsis?
reduces # of micro-organisms
| prevent: PPE
186
# sterile gloving
what is surgical aspesis or sterile technique?
elimination of all micro-organisms from an object or area to prevent contamination
187
# sterile gloving
What areas of a sterile field are considered sterile?
The top of the sterile drape and 1 inch in from all edges; anything below the waist or out of sight is not sterile.
188
# sterile gloving
what is the purpose of surgical asepsis?
## Footnote
3
* prevent contamination of an open wound
* isolate an operative/procedural area from unsterile environment
* procedural intervention (urinary cath, central line dressing change, insert surgical instruments into body)
189
# sterile gloving
rules of sterile technique: rule 1
a sterile object is only sterile when touched by another sterile object
190
# sterile gloving
contamination occurs when ...
## Footnote
6
* Touching a sterile item with a non-sterile hand or object
* reaching over a sterile field
* turning your back
* allowing sterile items to become wet
* field falling below waist level
* sits out too long
191
# sterile gloving
rules of sterile technique: rule 3
a sterile object of field out of range or below waist is contaminated
192
# sterile gloving
rules of sterile technique: rule 2
only sterile objects may be placed on sterile field
## Footnote
drop 6 inches above
193
# sterile gloving
rules of sterile technique: rule 4
a sterile object or field is contaminated by prolonged exposure to air
194
# sterile gloving
rules of sterile technique: rule 5
when a surface becomes wet, it becomes asterile
## Footnote
solution in bottle is sterile, the bottle isn't
195
# sterile gloving
rules of sterile technique: rule 6
the 1-2 in of the edgs of the sterile field are considered contaminated
196
# wounds
what is dehiscence?
spltting open of wound
197
# wounds
what is evisceration?
extrusion of the viscera outside the body
198
# wounds
wound care assessment: appearance
color
length x width x depth
redness/swelling
199
# wounds
wound care assessment: drainage
amount
color
consistency
odor
200
# wounds
wound care assessment: wound closure
sutures
staples
adhesives
glue
201
# wounds
wound care assessment: status
drains, tubes, etc.
unable to assess (covered w wound vac)
202
# wounds
wound care assessment: pain
location
quality
type
intensity
timing
setting
203
# wounds
What is serous drainage?
* Clear, watery fluid
* common in early healing or minor wounds.
204
# wounds
What is purulent drainage?
* Thick, yellow, green, or brown
* drainage indicating infection
205
# wounds
What are signs a wound may be infected?
Purulent drainage (yellow/green), foul odor, increased pain, warmth, redness, swelling, fever, delayed healing
206
# wounds
What are signs of a normal healing wound?
Pink granulation tissue, minimal serous drainage, no odor, no increased redness/swelling, edges approximating.
207
# wounds
What is serosanguineous drainage?
* Pale pink or watery blood-tinged fluid
* normal in early healing
208
# wounds
What is sanguineous drainage?
* Bright red, bloody drainage
* may occur with deep or fresh wounds.
209
# wounds
What is evisceration and how do you respond?
Protrusion of organs through a wound; cover with sterile saline-soaked gauze, keep NPO, call provider immediately
210
# wounds
What is dehiscence and what should you do if it occurs?
Partial or total separation of wound layers; cover with sterile, moist dressing and notify provider immediately.
211
# wounds
What is the difference between a partial-thickness and full-thickness wound?
Partial-thickness affects only the epidermis/dermis; full-thickness extends into subcutaneous tissue or deeper
212
# wounds
What kind of dressing is best for a dry, shallow wound?
Transparent film or hydrocolloid to maintain moisture
213
# wounds
What dressing is used for moderate to heavy drainage wounds?
Alginate or foam dressings—highly absorbent.
214
# wounds
What is a hydrogel dressing used for?
Dry or necrotic wounds—hydrates tissue and promotes autolytic debridement.
215
# wounds
When is negative pressure wound therapy (wound VAC) indicated?
For large, chronic, or draining wounds to promote healing and remove exudate
216
# wounds
What is a wet-to-dry dressing and when is it used?
A moist gauze applied and allowed to dry, then removed to debride necrotic tissue; not used for clean, granulating wounds.
217
# wounds
How do you clean a wound?
Use sterile technique and clean from least to most contaminated (center outward), using new gauze for each wipe.
218
# wounds
What is the Braden Scale used for?
Predicting pressure injury risk; assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
219
# wounds
what are pressure ulcers?
local damage to skin and tissues follwing prolonged/intense pressure
220
# wounds
where do pressure ulcers commonly form?
bony prominences (coccyx, heels, elbows)
221
# wounds
risk factors for pressure ulcers
## Footnote
10
1. age
1. immobility
1. incontience/excess moisture
1. skin friction/shearing
1. vascular disorders/impaired circulation
1. obesity
1. inadqeuate nutrition or dehydration
1. edema
1. sensory deficits or chronic diseases (DM)
1. impaired cognitive functioning
222
# wounds
What is a Stage 1 pressure ulcer?
* Non-blanchable erythema of intact skin
* skin may be red, warm, or painful, with no open wound
* epidermis
223
# wounds
What is a Stage 2 pressure ulcer?
* Partial-thickness skin loss with exposed dermis
* appears as a shallow open ulcer or blister
* maybe sloughing
224
# wounds
What is a Stage 3 pressure ulcer?
* Full-thickness skin loss (epi,dermis, into subq)
* may see fat, but no exposed bone, tendon, or muscle
* Slough or tunneling may be present.
225
# wounds
What is a Stage 4 pressure ulcer?
* Full-thickness tissue loss with exposed bone, tendon, or muscle
* includes slough, eschar, or tunneling
226
# wounds
What is an Unstageable pressure ulcer?
Full-thickness tissue loss in which the wound base is obscured by slough or eschar, preventing accurate staging.
227
# wounds
What is a Deep Tissue Pressure Injury (DTPI)?
Intact or non-intact skin with persistent deep red, maroon, or purple discoloration from underlying soft tissue damage
228
# wounds
What is woven gauze (sponges) and when is it used?
* Woven gauze is an absorbent dressing used to clean, pack, or cover wounds
* It's ideal for wounds with moderate exudate and is commonly used for wound packing, absorbing drainage, or providing mechanical debridement (when removed dry).
🩺 Use for:
Stage 2–4 pressure injuries
Surgical wounds
Wounds requiring frequent dressing changes
229
# wounds
What is nonadherent material and when is it used?
* Nonadherent dressings have a shiny, non-stick surface that won’t stick to granulating tissue.
* They help protect the wound bed and allow for easier, less painful dressing changes.
🩺 Use for:
Minor abrasions or wounds
Skin grafts
Donor sites
Wounds with new epithelial tissue
230
# wounds
What is a damp-to-damp (moist) dressing and when is it used?
* A damp (not soaked) sterile gauze is packed into the wound and kept moist with sterile saline.
* As it dries, it gently debrides necrotic tissue without harming viable tissue.
🩺 Use for:
Wounds requiring debridement of slough or necrotic tissue
Deep wounds with irregular shapes
Pressure injuries with tissue loss
## Footnote
Must be changed before it dries completely to avoid removing healthy tissue.
231
# wounds
What is self-adhesive transparent film and when is it used?
* Transparent films are clear, adhesive dressings that allow oxygen exchange and moisture retention while keeping out bacteria.
* They're thin and flexible—ideal for minor wounds or protection over IV sites.
🩺 Use for:
Stage 1 pressure injuries
Minor burns or abrasions
Secondary dressing to secure other dressings
IV catheter sites
Preventing friction injuries
## Footnote
Not for use on heavily draining or infected wounds.
232
# wounds
Hydrocolloid dressings
* Hydrocolloid dressings are occlusive, moisture-retaining dressings that form a gel-like layer over the wound to promote autolytic debridement.
* They provide a barrier to bacteria and can stay in place for several days.
🩺 Use for:
Stage 1–2 pressure injuries
Shallow, non-infected wounds
Partial-thickness wounds
Wounds with light-to-moderate drainage
## Footnote
✅ Promotes healing in clean wounds
🚫 Not for infected or heavily draining wounds
233
# wounds
What is a hydrogel dressing and when is it used?
* Hydrogels are water- or glycerin-based dressings that provide moisture to dry wounds and help with pain relief
* They assist in autolytic debridement and cool the wound surface.
🩺 Use for:
Dry, necrotic wounds
Stage 2–4 pressure ulcers
Burns
Wounds with minimal exudate
## Footnote
✅ Soothes painful wounds
🚫 Not for heavily draining wounds
234
# wounds
What is an alginate dressing and when is it used?
* Alginate dressings are made from seaweed and form a gel when in contact with wound exudate, making them highly absorbent
* They support hemostasis and are good for wet wounds.
🩺 Use for:
Moderate to heavily exudating wounds
Tunneling wounds
Stage 3–4 pressure injuries
Wounds with bleeding (promotes clotting)
## Footnote
✅ Requires secondary dressing
🚫 Not for dry wounds
235
# wounds
What is a collagen dressing and when is it used?
* Collagen dressings are made from animal collagen and stimulate new tissue growth and cellular migration
* They help guide wound healing and support granulation.
🩺 Use for:
Chronic, non-healing wounds
Partial- and full-thickness wounds
Stage 3–4 pressure injuries
Surgical wounds
Diabetic ulcers
## Footnote
✅ Speeds up wound healing
🚫 Not for necrotic or infected wounds
236
# wounds
What is wound packing, and when is it used?
* Wound packing involves filling a deep wound with moist (usually saline-soaked) gauze or other dressings to promote healing from the base up and prevent premature closure.
🩺 Use for:
Deep wounds
Tunneling wounds
Stage 3–4 pressure ulcers
Surgical wounds healing by secondary intention
## Footnote
✅ Encourages granulation
🚫 Don’t pack too tightly—it can damage tissue
237
# wounds
What is a Wound VAC (Negative Pressure Wound Therapy)?
* A wound VAC applies negative pressure suction through a foam dressing sealed with a transparent film
* It removes excess fluid and promotes wound edge approximation and granulation tissue growth.
🩺 Use for:
Large, complex wounds
Stage 3–4 pressure ulcers
Dehisced surgical wounds
Wounds with heavy drainage
238
# wounds
what are the different ways to secure dressings?
## Footnote
3
tape
ties
binders
239
# wounds
staple removal process
## Footnote
4 steps
1. identify # of staples to remove
2. insert the 2 prong tip under the staple in the middle
3. slowly close the ends of together
4. gently lift up and out of skin
240
# wounds
suture removal process
## Footnote
6 steps
1. type of suturing used
2. # to be removed
3. NEVER pull the visible part of a stuture throihg underlying tissue
4. cleanse with normal saline
5. clip suture material as close to skin on one side as possible
6. pull through the other side
241
# drains
when are drains used?
when drainage interferes with healing
242
# drains
What is a Penrose drain and how does it work?
* Penrose drain is a passive drain made of soft rubber tubing
* It allows fluid to drain by gravity and capillary action onto a dressing—no collection device
* OPEN system
243
# drains
What is a Jackson-Pratt (JP) drain, and how does it work?
* Jackson-Pratt drain is a closed suction drain connected to a bulb reservoir
* Suction is created by compressing the bulb
* CLOSED system
244
# drains
What is a Hemovac drain, and how does it work?
* The Hemovac is a closed system drain with a larger capacity than JP
* It uses spring-loaded suction to remove fluid from surgical sites
* CLOSED system
245
# drains
drain considerations:
________________ assessment and intervention
admin ____________ and ________ (and montior)
wound cleansing and ________
meet ________ needs
adequate _______
document
analgesics and antimicrobials
irrigation
caloric
hydration
246
# wounds and drains
considerations for wound cleaning
## Footnote
4
from least to most
gentle pressure
avoid tissues/cotton balls (get stuck)
use gauze
247
What are the types of medication distribution systems?
Unit dose systems
Automatic Medication Dispensing Systems (AMDS)
248
What are the four types of medication orders?
Standing (routine), PRN, Single (one-time), and STAT orders
249
What is the pharmacist’s role in medication administration?
Prepare and distribute medications
250
What are the responsibilities of the nurse in medication administration?
Check correctness
assess self-administration
determine timing
administer correctly
monitor effects
teach patients
never delegate to assistive personnel
251
What are the three medication label checks?
1. When removing from storage
2. When preparing the med
3. At bedside before administering
252
List patients' medication rights.
To be informed
to refuse
have history taken
know about experimental meds
receive labeled meds safely
get supportive therapy
avoid unnecessary meds
be told if involved in research
253
How should oral meds be crushed or altered?
Scored tablets can be split; crushed meds should be mixed with small amount of food/fluid; some meds (e.g. enteric coated) cannot be crushed
254
What are parenteral medication routes?
Subcutaneous, intramuscular, intravenous, intradermal
255
What are non-parenteral medication routes?
Oral
enteral-tube
topical
ophthalmic/otic
inhalation
vaginal
rectal
irrigations
256
How are sublingual and buccal medications administered?
Sublingual: under the tongue
Buccal: between molars and cheek
Neither can be chewed, cut, or swallowed
257
What are best practices for topical medication application?
Apply gloves, document placement/removal, rotate patch sites, use labels if patch is clear
258
7 medication rights
Right Patient
Medication
Dose
Route
Time
Indication
Documentation
259
What is the first thing to do when a medication error occurs?
Assess the patient’s condition
260
what are standing orders?
consistent
normal home meds
for a certain pd of time
261
what are PRN orders?
as needed
don't have to call Dr
262
what are single (one-time) orders?
meds that are only used once
ex) benadryl b4 blood transfusion
263
what are stat orders?
right now
ex) NO for CP
264
What are the next steps after assessing a patient following a med error?
Notify provider, report the incident, complete an occurrence report, document, and report near misses
265
Guidelines for rectal medication administration?
Insert with gloved hand, left Sims’ position for 5 min, lubricate with water-soluble gel, may need enema first
266
Guidelines for vaginal medication administration?
Use gloves, lie supine 10 min, clean technique, may use perineal pad
267
How do nebulizers deliver medication?
Continuously over a short time, using a mist inhaled through air or oxygen
268
Key points for ear instillation?
Room temp solution, sterile, don’t occlude canal, check for eardrum rupture if drainage
269
What are precautions for nasal sprays/drops?
Avoid rebound effect; excess can cause systemic effects, especially in children
270
What are key instructions for eye instillation?
Avoid cornea, don’t touch eye with applicator, use only for affected eye, and teach how to use intraocular disks
271
What should a nurse know about administering medication via inhalers?
Route: Delivered via nasal/oral passages or tracheostomy tubes
Mechanism: Medication is absorbed through large airway passages with a vascular alveolar-capillary network
Action: Can be local (e.g., bronchodilators) or systemic
272
How do you ensure accuracy in medication administration?
Avoid distractions, only give meds you prepared, never leave unattended, document right away, and check med label vs MAR 3x
