Flashcards in Final Deck (95):
What is Subjective Data
Information provided by the individual that we cannot visibly see
What is Objective Data
Data obtained through physical assessment, lab results, etc.
What are First-level Priority Problems?
Emergent, life-threatening, and immediate. They require urgent measures such as establishing an airway.
What are Second-level Priority Problems?
Require prompt intervention to prevent deterioration; may include a mental health change or acute pain.
What are Third-level Priority Problems?
Important but can be addressed after dealing with more urgent problems. Example is patient with lack of knowledge.
What are Collaborative Problems?
Physiological complications in which the approach to treatment encompasses multiple disciplines.
What is a Complete data base?
aka Total Health; includes a complete health history and findings from a full physical examination
What is an Episodic database?
aka Problem-centered; used for limited or short-term problem
What is a Follow-Up database?
Evaluates the status of any identified problem at regular intervals to follow up on short-term or chronic health problems.
What is Culturalism?
Assuming that people act in a specific way because of their culture
What is Cultural Competence?
The application of knowledge, skills, attitudes, or personal attributes to diverse populations with the aim of developing respectful relationships.
What is Inspection?
Close, careful observation of the patient as a whole and then of each body system.
What is Palpation?
The use of touch to assess texture, temperature, moisture, and organ location and size. Also helps to identify swelling, pulsations, crepitation, lumps, and tenderness.
What is Percussion?
Tapping the patients skin with short, sharp strokes to create percussion sounds. Used to assess the location, size, and density of an organ.
What is Auscultation?
Listening to sounds made by the body usually using a stethoscope. The diaphragm is used for detecting high-pitched sounds and the bell for low-pitched sounds such as murmurs.
What does PQRSTU stand for?
Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing, and Understanding
What are the 4 areas of the general survey?
Physical Appearance, Body Structure, Mobility, and Behavior
What do we assess for when palpating a pulse?
Rate, rhythm and force. Rate ranges from 50-90 beats (60-100 for testing), rhythm is even and regular, and force is determined on a scale from 0-3.
How long do we count respiration for and what is the average?
Count for 30 seconds unless abnormal then 1 minute. Average is 10-20 per minute.
How should the cuff be place to obtain an accurate measurement?
The width of the cuff's rubber bladder should equal 40% of the circumference of the patients arm. The length of the bladder should equal 80% of this circumference.
What happens if a BP cuff is too narrow?
Yields a falsely high pressure.
What happens if a BP cuff is too wide?
Yields a falsely low pressure.
What is Somatic pain?
Pain that can be superficial from skin and subq tissure, or deep from joints, tendons, muscles or bones.
What is Visceral Pain?
Pain originating from larger interior organs.
What is Neuropathic Pain?
Abnormal processing of the pain message as a result of an injury to nerve fibers.
What is Referred pain?
Originates in one location but is felt at another side.
What is Acute Pain?
Short-term pain that ends after the injury heals.
What is Chronic Pain?
Persistent long-term pain that continues for 6 months or longer.
What are some key properties of Skin?
Protection, prevents penetration, allows perception of touch, pain, temp, and pressure, absorbs/excretes substances, and produce Vitamin D
What are some developmental differences in skin between ages?
Infants cannot prevent fluid loss or regulate temperature. Aging causes changes in the stratum corneum that give chemicals easier access to the body and causes other changes that lead to wrinkling. Pregnancy causes pigment changes and stretch marks.
When inspecting hair what would you look for?
Color, texture, distribution, scalp lesions & infestations.
When inspecting nails what do you look for?
Shape/contour, consistency, color and capillary refill.
What are some health promotions and self care teachings about skin?
Avoidance of exposure to UV rays, newborn skin variations such as jaundice, and age-related changes such as keratoses.
What does the thoracic cage consist of?
Sternum, 12 pairs of ribs, 12 thoracic vertebrae and the diaphragm.
On the anterior thorax what are included in the surface landmarks?
Suprasternal notch, sternum, sternal angle (angle of louis), costal angle.
On the posterior thorax what are included in the surface landmarks?
Vertebra prominens, spinous processes, inferior border of the scapula, twelfth rib
How many lobes do the lungs have?
Right lung has 3 left has 2
What is the pleurae and the pleural cavity?
The pleurae form an envelope between the lungs and the chest. The pleural cavity is a potential space that contains a few milliliters of lubricating fluid which prevents friction as the lungs move during respiration.
What happens during diastole and systole?
In diastole the ventricles relax and fill with blood. In systole the heart contracts and pumps from the ventricles into the pulmonary and systemic arteries.
What is the first heart sound?
S1; results from closure of the atrioventricular valves.
What is the second heart sound?
S2; results from closure of the semilunar valves.
What are murmurs?
Gentle, blowing or swooshing sounds resulting from turbulent blood flow.
ECG- What happens during P-Wave?
Depolarization of Atria
ECG-What happens during QRS?
Depolarization of Ventricles
ECG-What happens during T Wave?
Repolarization of the ventricles
What are major risk factors for heart disease?
High BP, smoking, high cholesterol, obesity and type 2 diabetes.
How often do normal bowel sounds occur?
5-30 times per minute but listen for 5 minutes of bowel sounds are absent
How many bones do we have?
What are the 3 types of muscle?
Skeletal, smooth & cardiac
How many of each vertebrae?
5 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3/4 coccygeal
What does the frontal lobe control?
Personality & Behavior
What does the patietal lobe control?
What does the Occipital Lobe control?
What does the temporal lobe consist of?
hearing, taste, smell. Also contains Wernickes area which is associated w/ language comprehension
What dose the hypothalmus control?
Respiratory, temp, HR, BP, sleep, appetite
What does the Cerebellum control?
Motor coordination, equilibrium and muscle tone
What does the brain stem consist of?
Midbrain, pons, medulla oblongata
How many pairs of spinal nerves?
What cranial nerve is being tested by assessing the blink reflex?
Trigeminal Nerve; Cranial Nerve 5
What cranial nerve is being assessed when a patient is being asked to shrug their shoulders against resistance?
Spinal Accessory Nerve; Cranial Nerve 11
Cranial Nerve 3 mediates which function?
Extraocular eye movement, pupil constriction and dilation
When a patient is asked to puff out their cheeks what cranial nerve is being tested?
Nerve 7; Facial
What cranial nerve is being tested when a patient is being asked to move their tongue side-to-side and up and down?
Cranial nerve 12; Hypoglossal
When the pupils constrict from looking at an object far away, then close, what is this called?
Accommodation; Reflex action of eye at a distant then near object
The mental perception of depth by the senses
What are deep tendon reflexes assessing?
What is two point discrimination?
When you touch 2 points of a patient and they have to identiy where they were touched
Describe a positive Babinksi test
a reflex action in which the big toe remains extended or extends itself when the sole of the foot is stimulated, abnormal expect in young infants. In adults this can indicate damage to the spine
What is the usual pupil diameter range?
Equal, round and 3mm
What is the Glasgow Coma Scale used to evaluate?
Level of Conscisouness
What are the 3 functions measured by the GCS?
Eyes open, verbal response, motor response
How would you assess consensual pupil reaction of the left eye?
Shine a light in the right eye and see if the left eye reacts
Define muscle spasicity
when your muscles contract, become stiff, or spasm involuntarily
weakness or paralysis and reduced muscle tone
What does Contracture mean?
shortening and hardening of muscles, tendons, and other tissue leading to deformity.
Which side of the stethoscope is used to assess the lungs?
Describe what is being assessed with tactile fremitus
ax of the lungs by either the vibration intensity felt on the chest wall
Describe what is meant by Adventitious breath sounds
adventitious breath sounds are abnormal sounds that are heard over a patients lungs and airways
What other sites can be used to assess pulse oximetry other than fingers?
Tip of the nose or ear
What conditions would you expect to hear absent bowel sounds?
What cardiac alteration can occur during pregnancy?
Increase in cardiac volume and decrease in BP
Which is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs?
Roll toward the left side
The ability of the heart to contract independently of any signals or stimulation is caused by:
Automaticity; the heart can contract by itself, independent of any signals or stimulation from the body.
The jugular venous pressure is an indirect reflection of the:
Hearts efficiency as a pump
What do the semilunar valves separate?
The ventricles from the arteries; the AV valves separate the atria and ventricles
What is the first heart sound produced by?
Closure of the AV valves
What does heart sound S1 coincide with?
Carotid artery pulse
What is a bruit caused by?
Turbulent blood flow through the carotid artery
Arteriosclerosis refers to:
Thickening and loss of elasticity of teh arterial walls
One of the leg’s deep veins is the:
Popliteal; the femoral and popliteal veins are the deep veins in the leg
Palpable inguinal lymph nodes are:
Normal if small (<1cm), movable, and nontender
What occurs in Pulsus Paradoxus?
Beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration
A water-hammer "Corrigans" pulse is associated with what?
Aortic valve regurgitation
In young children, what does the Thymus gland product?