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NURS 335 > Final > Flashcards

Final Flashcards

(46 cards)

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1
Q

Most common Area for Cancerous Findings in Breasts

A

Tail of Spence
Upper lateral quadrant

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2
Q

Breast Cancer in Men

A
  • Usually detected as a lump in chest under or near the nipple or armpit
  • Less than 1% of breast cancers in men
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3
Q

Mastitis

A

Infection of the mammary glands
- Most common in women who are breast feeding
- Caused by milk stasis and bacterial infection
- Can progress to lactational abscess if untreated

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4
Q

Peau d’orange

A

Caused by breast edema from blocked lymph drainage and indicates advanced cancer

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5
Q

Palpation of Breast

A
  • Palpation of AXILLAE best done w/ pt SITTING
  • Palpation of BREAST TISSUE best done w/ pt SUPINE and arm slightly to the side, no pillow under head,
  • Palpate rectangular angle from clavicle to inframammary fold (bra line) and from mid sternum to posterior axillary line
  • Both horizontal and vertical approaches are fine
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6
Q

Checking for nipple discharge

A

Compressing nipple to check for discharge is NOT part of regular screening and NOT useful sign of cancer

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7
Q

Bimanual Technique

A

For pendulous breasts
- Pt sitting upright leaning forward slightly
- Place one hand underneath breast on inferior side while palpating with other hand

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8
Q

Transillumination

A

Used to differentiate between fluid filled mass and solid mass

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9
Q

Gynecomastia

A

Occurs in men w/ an estrogen and androgen imbalance
- Obese men and men on steriods

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10
Q

9 Regions of the Abdomen

A

R Hypochondriac - Epigastric - L Hypo
R Lumbar - Umbilical - L Lumbar
R Inguinal - Hypogastric - L Inguinal

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11
Q

Lymphadenopathy (Breast)

A

Swelling of lymph nodes post-mastectomy from blocked lymph nodes or infection

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12
Q

Auscultation of Abdomen

A

Begin at Ileocecal valve and move clockwise
- Should be 5-30 sounds/min
- Bruits would be over aorta, renal and iliac arteries (
- Venous hums near liver and over umbilicus (EXPECTED IN PREGGOS AND KIDS)
- Friction rubs over liver and spleen

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13
Q

Finding Appendix

A

McBurney’s Point
Find umbilicus and go down laterally towards upper pelvic bone at an angle, 2/3 between those two points

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14
Q

Percussion of Abdomen

A

Used to determine organ size and tenderness
Expected Findings = dullness over liver (RUQ) and tympany over LUQ
Usually tympanic throughout most of abdomen
- Percuss kidney’s with hand over and tap with fist

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15
Q

Liver Span Test

A

Start at MCL 3rd ICS and percuss down until you hear it go from resonant to dull (between 5-7 ICS). Mark it. Then Go from MCL at umbilicus level and go up. When it goes from resonant to dull mark it. Measure distance

Expected Findings:
- 6-12cm
- If bigger than 12, measure again at Midsternal line

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16
Q

Castell’s Method for Splenic Percussion

A

Find last intercostal space, left anterior axillary line
1) Percuss on expiration
2) Have client inhale and hold – 3)Percuss
Expiration = Resonant or tympany
Inspiration = Positive if Dull; expected is resonant or tympany (no change)

Spleen moves down w/ inspiration
-9th ICS (have pt inhale, percuss and should be resonant, then have pt exhale, percuss and should still be resonant. If it’s dull, the spleen is probably enlarged)

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17
Q

Neck Movements

A

Flexion
Extension
Hyperextension
Rotation
Abduction

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18
Q

Shoulder Movements

A

Flexion
Extension
Hyperextension
Circumduction
Abduction
Adduction
Internal Rotation
External Rotation

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19
Q

Elbow Movements

Study These Flashcards
A

Flexion
Extension

20
Q

Wrist Movements

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A

Flexion
Extension
Hyperextension
Radial Deviation
Ulnar deviation

21
Q

Finger Movements

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A

Flexion
Extension
Hyperextension
Finger-thumb opposition
Abduction
Adduction

22
Q

Hip Movements

23
Q

Knee Movements

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A

Flexion
Extension

24
Q

Ankle Movements

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A

Dorsiflexion
Plantar flexion
Inversion
Eversion

25
Toe Movements
Flexion Extension Hyperextension Abduction
26
Phalen Test
Evaluates for carpal Tunnel Syndrome - "Upside down prayer pose" w/ backs of hands together for 60sec - Expected should be painless Positive Result = numbness, burning or pain
27
Tinel Test
Carpal Tunnel - Percuss over median nerve on inner aspect of wrist - Positive test = pain, tingling, numbness
28
Bulge Test
Differentiate between soft tissue swelling and accumulation of excess fluid behind patella' - "milk" down knee on medial side and then press on lateral side to see if medial bulges - Bulge = mild joint effusion or liquid accumulation
29
McMurray Test
Checks for meniscus injury - Pt supine, flexing hip and knee - Supports knee w/one hand and holds foot w/ other, rotating foot laterally - slowly extend knee looking for clicking or pain
30
Ballottement
Evaluates presence of large accumulation of fluid behind the knee
31
Thomas Test
Assesses presence of a flexion contracture of the HIP - One legged gas releasing pose (no hands) - If extended leg raises, its a positive test
32
Drawer Sign
Checks for knee injury
33
Lasegue Test: Straight Leg Raising
Checks for herniation of lumbar disc and nerve irritation or pressure Positive result = pain in leg when raised (record degree of elevation)
34
Trendelenburg Test
Assesses for hip disease w/ muscle weakness - Stand behind pt and ask to raise one leg Positive Result = Hip drops when pt is standing on weak side (Should remain horizontal and equal)
35
Drop Arm Test
Assess for rotator cuff injury - Pt abducts arm to shoulder level or 90 degrees Positive result = arm drops rapidly or has severe pain
36
Ottawa Rules
Ankle injury
37
Barlow-Ortolani Sign
Infant hip test
38
Alterations in Muscle Tone Terms
Atony = lack of residual tension Hypotonicity = Diminished tone of skeletal muscles Spasticity = Muscles are stiff and movements awkward
39
Muscle Strength Rating Scale
5/5 (100%) = Complete ROM against gravity and full resistance 4/5 (75%) = Complete ROM against gravity and MODERATE resistance 3/5 (50%) = Complete ROM against gravity 2/5 (25%) = Complete ROM W/ JOINT SUPPORTED (**No ROM against gravity**) 1/5 (10%) = Muscle contraction detectable but NO MOVEMENT OF JOINT 0/5 (0%) = No visible muscle contraction
40
Torticollis
Lateral deviation of the neck caused by acute muscle spasms, congenital conditions or incorrect head posture to correct vision changes
41
**LOOK AT MORSE FALL SCALE
42
Expected Findings for Male Genitalia and Rectum
Penis: - Prepuce retracts easily - White, cheesy material present (smegma) - Glans smooth - Urethral meatus opens readily and free of discharge - No lateral curvature or flexion Scrotum: - Wrinkled, loose, free of lesions - Spermatic cord palpable, smooth bilaterally Testes: - Left testis lower than right - Testes firm, smooth, slightly rubbery on palpation Inguinal: - Free of nodules - Epididymus palpable - NONpalpable lymph nodes bilaterally Anus: - Anal opening darkly pigmented, hairless, moist, closed - External sphincter tone intact Rectum: - smooth, nontender rectal walls Prostate Gland: - Smooth, rubbery, heart-shaped gland - slightly moveable
43
Tanner Stages of Male Development
Stage 1: - No pubic hair - Testes & penis small - <10 Stage 2: - Sparse thin hair at base of penis - Testes enlarge - Scrotal skin becomes coarser/redder - 10-13 yr Stage 3: - Scrotum and testes continue to grow - Penis lengthens w/ diameter increasing slowly - Pubic hair increases becoming darker, coarse, and curly - 12-14 Stage 4: - Penis and testes continue to grow - Pubic hair extends across pubis BUT spares the medial thighs - 13-15 Stage 5: - Penis at full size - Pubic hair is diamond-shaped w/ adult colour - Texture extends to surface of medial thighs - 14-17
44
Expected Findings of Female Genitalia and Rectum
External: - Labia majora & minor SYMMETRICAL Internal: - Cervix midline, smooth, evenly pink & projects 3cm into vagina - Vaginal wall pink, moist, smooth, totally rugated (wrinkled) Bimanual Examination = cervix smooth and firm, Fundus round and firm, uterus moves freely Rectovaginal Examination = posterior wall of uterus firm, smooth and moves freely, no nodules
45
Menopause
12 consecutive months without menses - Usually occurs between 48-51 - Ovaries stop producing estrogen and progesterone causing uterus to droop and cervix to shrink - Uterus becomes smaller, ovaries shrink
46
Tanner Stages of Female Development
Stage 1: - Vellus over the pubes is not further developed than that over the anterior abdominal wall (no pubic hair) Stage 2: - Long, slightly pigmented, downy hair that is straight or only slightly cured appears chiefly along labia Stage 3: - Hair is considerably darker, coarser, and more curled - Hair spreads sparsely over the junction of the mons pubis Stage 4: - Hair is now adult type but the area covered by it is still considerably smaller than most adults - No spread to the medial surface of thighs Stage 5: - Hair is adult in quantity and type - Spread to medial surface of thighs

NURS 335 (4 decks)

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