Final Exam Flashcards
(210 cards)
1
Q
What is the purpose of performing a health assessment?
A
To make a clinical judgment or diagnosis about the individual’s health state or response to actual or risk health problems and life processes, as well as diagnosis about higher levels of wellness.
2
Q
subjective data
A
what the patient says about himself or herself
3
Q
objective data
A
what you obtain through physical examination
4
Q
Complete assessment
A
complete health history & full physical exam. describes the current & past health state & forms a baseline. collected by a primary physician
5
Q
problem focused assessment
A
limited or short-term problem. collect a “mini” database, smaller in scope & more targeted than the complete database. Concerns mainly one problem, one cue complex, or one body system. used in all settings.
6
Q
Follow-up assessment:
A
he status of any identified problems should be evaluated at regular & appropriate intervals. What change has occurred? is the problem getting better or worse?
use in all settings to follow up both short term & chronic health problems
7
Q
Emergency assessment
A
urgent, rapid collection of crucial information & often is compiled concurrently w/ lifesaving measures. emergency rooms or emergency.
8
Q
open-ended questions
A
prompts pt’s to describe a situation in more than one or two words. leads to discussion in which pt’s actively describe their health status
9
Q
closed-ended questions
A
limit the pt’s answers to yes or no or a number or frequency of symptoms. elicit cold facts
10
Q
Review the positive nonverbal behaviors that promote communication during an interview and be able to identify examples of each.
A
Physical appearance Posture Gestures Facial expression Eye contact Voice Touch
11
Q
facilitation
A
encourage client to say more, shows a person that you are interested
12
Q
reflection
A
echoes the client’s words by repeating part of what a person has just said. Mirroring client’s words can help person elaborate on a problem
empathy: names a feeling and allows its expression. allows a person to feel accepted & strengthens rapport
13
Q
clarification:
A
use this when the person’s word choice is ambiguous or confusing. Also used to summarize the person’s words to make them clearer & ask if you’re on the right track
14
Q
confrontation
A
this response includes your own thoughts & feelings. You have observed a certain action, feeling, or statement & you now focus the person’s attention on it. you give your honest feedback on what you see or feel. ex: “you say it doesn’t hurt but when i touch you here, you grimace”
15
Q
leading or biased questions
A
Asking a man, “you dont smoke, do you?” implies that one answer is better than another. if a person wants to please you, either he is forced to answer in a way corresponding to your values or he feels guilty when he must admit to the other answer.
16
Q
ten traps of interviewing
A
- providing false assurance or reassurance
- giving unwanted advice
- using authority: “your dr/nurse knows best
- using avoidance language- “passed on” to avoid reality or hide their feelings
- distancing- impersonal speech to put space bw a threat & the self. ex: “there is a lump in the left breast”
- using professional jargon- adjust your vocab to ensure understanding
- using leading or biased questions
- talking too much
- interrupting
- using “why” questions- answer to why questions is “because”
17
Q
intimate zone:
A
0 to 1.5 feet.
visual distortion occurs, best for assessing breath & other body odors
18
Q
personal distance:
A
1.5 to 4 ft.
perceive as an extension of the self, similar to bubble. voice moderate, body odors inapparent, no visual distortion, much of physical assessment occurs at this distance
19
Q
social distance:
A
4 to 12 ft.
used for impersonal business transactions. perceptual info much less detailed. much of the interview occurs at this distance.
20
Q
public distance:
A
12+ feet.
interaction with others impersonal speaker’s voice must be projected. subtle facial expressions imperceptible
21
Q
What are the techniques for promoting therapeutic communication and building rapport?
A
- time & place of the interview & succeeding physical exam.
- intro of self & a brief explanation of your role
- the purpose of the interview
- how long it will take
- expectation of participation for each person
- presence of any other people
- confidentiality & to what extent it may be limited
- any costs that the pt must pay
22
Q
What is the purpose of using silence during an interview?
A
- gives the patients time to collect his or her thoughts
- gives you an opportunity to observe the pt unobtrusively & note nonverbal cues.
- Silence also gives you time to plan your next approach
23
Q
Review the “rules” of using an interpreter.
A
- before locating an interpreter, identify the language the person speaks at home. it may differ from the language spoken publicly
- when possible, use a trained interpreter, preferably one who knows medical terms
- avoid interpreters from a rival tribe, state, region, or nation
- be aware of gender, age, & socioeconomic differences bw the interpreter & the client
24
Q
biographic data
A
name, address, phone #, age & birth date; birthplace, gender, marital partner status, race, ethnic origin, & occupation. primary language & change in occupation
25
source of history
record who furnishes the info.
judge how reliable & how willing he or she is to communicate. note if they appear well or ill
26
chief complaint (CC)
reason for seeking care using pts own words. ask about symptoms. NOT A DIAGNOSIS
27
Is the information in the health history subjective or objective data?
subjective
28
What is included in a functional assessment?
Social, self-care, ADL, & IADL
29
What are the guidelines for recording the reason for seeking care?
Use patient’s own words in quotation and record date and time.
30
Symptoms
subjective sensation that the person feels from the disorder.
31
Sign
objective abnormality; *seen* by examiner
32
What is the purpose of the genogram?
A pedigree or genogram is a graphic family tree that uses symbols to depict the gender, relationship, & age of immediate blood relatives in at least 3 generations, such as parents, grandparents, & siblings. useful in showing info concisely
33
inspection
always 1st & continual. it is close, careful observation of the patient as a whole & of each body system. Use the pt's body as the control & compare the right & left sides of the body to determine symmetry. Requires good lighting
34
Palpation
Use of touch to assess texture, temp, moisture, organ location & size Helps identify swelling, vibrations, pulsations, lumps or masses, tenderness/pain
35
Percussion
tapping the pt's skin with short, sharp strokes to create percussion sounds. used to assess the location, size, and density of an organ, detect an abnormal mass, or elicit a deep tendon reflex
36
Auscultation
listening to sounds made by the body using a stethoscope. Heart, blood vessels, lungs, & abdomen are commonly auscultated areas
37
Palpation- fingertips
are used for fine tactile discrimination
38
Palpation- fingers & thumb
are ideal for detecting position, shape and consistency of an organ or mass
39
Palpation- back of hand (dorsal) & fingers
are good for determining temperature
40
Palpation- base of fingers & ulnar surface of hand
is best for assessing vibration
41
Light palpation
evaluates surface characteristics & identifies areas of tenderness
42
Deep palpation
assesses an organ or mass deeper in body cavity
43
Bimanual palpation
is the use of both hands to envelop or capture certain body parts or organs, such as the kidneys
44
Diaphragm
breath, bowel, normal heart sound/ high-pitched/ firmly held
45
Bell
extra heart sound & murmur/ soft low-pitched/ lightly held
46
What is the purpose of the general survey?
study of the whole person, covering the general health state and any obvious physical characteristics. Begin general survey when you first encounter the person.
47
Is the data collected objective or subjective data?
objective
48
physical appearance
age, sex, level of consciousness, skin color, facial features, signs of distress
49
body structure
stature, nutrition, symmetry, posture, position, & body build or contour. In this area, obvious physical deformities are noted
50
mobility
concerned with gait & range of motion
51
behavior
considers facial expression, mood and affect, speech, dress & personal hygiene
52
Oral temperature
accurate & convenient. It may not be appropriate for a patient who is comatose or confused, has a wired mandible or facial dysfunction, or cannot close the mouth
*Use blue tip of electronic probe*
53
Rectal temperature
-use when other routes are not practical. (comatose, confused pts, pts in shock, people who cant close mouth with breathing or oxygen tubes)
-disadvantages are pt discomfort & time consuming & disruptive nature of the activity
use red tip of electronic probe. insert 2-3 cm (1 in) into rectum, directed toward umbilicus. Hold in place
54
What is the procedure for taking a pulse?
- Using the pads of first 3 fingers, palpate the radial pulse, if rhythm is regular, count the number of beats in 30 seconds and multiply by 2. If rhythm is irregular count for a full minute. Start first beat at 0.
- normal is 50-95 bpm
55
How is the force of a pulse recorded?
3+ full bounding
2+ normal
1+ weak thread
0- absent
56
Review the step-by-step procedure for taking a blood pressure. avoid smoking or drinking caffeinated beverages 30 min prior to measurement
- ensure the room is quiet & comfortably warm
- pt should be seated quietly in a chair with feet on the floor for at least 5 min
- pts arm should be FREE of clothing
- palpate the brachial artery
- position the arm so that the brachial artery is at heart level
- rest the arm on a table a little above the pts waist, or support the pts arm with your own at his mid-chest level
57
How does cuff size make a difference in BP readings?
- The width of the cuff's bladder should equal 40% of the circumference of the person's arm. The length of the bladder should equal 80% of this circumference.
- A cuff that is too narrow yields a falsely high pressure
- A cuff that is too wide yields a falsely low pressure
58
Annular
circular
| begins in center & spreads to periphery (ex: ringworm, tinea versicolor, pityaris rosea)
59
confluent
run together (urticarial hives)
60
grouped
cluster of lesions (vesicles of contact dermatitis)
61
gyrate
twisted, coiled spiral, snakelike
62
discrete
remain separate (acrochordon or skin tags, acne)
63
zosteriform
linear arrangement along a unilateral nerve route (herpes zoster)
64
linear lesions
a scratch, streak, line or stripe
65
How does the nurse assess for skin mobility and turgor, and what is an abnormal finding? What conditions are associated with abnormal findings?
Pinch up a large fold of skin on the anterior chest under the clavicle; mobility is the ease of rising and turgor is ability to return to place
promptly when released.
Edema- decreased mobility
Severe dehydration or extreme weight loss- poor turgor
Scleroderma- hard skin, decreased mobility.
66
PALLOR= PALE SKIN
Anemia
local arterial insufficiency
albinism
vitiligo
67
ERYTHEMA= REDNESS
Hyperemia
Polycythemia
carbon monoxide poisoning
Venous stasis
68
CYANOSIS= BLUISH SKIN
increased amount of unoxygenated hemoglobin
central chronic heart failure & lung disease cause arterial desaturation
peripheral exposure to cold, anxiety
69
JAUNDICE= YELLOW
Increased serum bilirubin, more than 2 to 3 mg/100 ml from liver inflammation or hemolytic disease such as after severe burns, some infections
70
xerosis
dry skin
71
seborrhea
oily skin
72
pruritus
skin itching
73
What are the danger signs for cancerous lesions (ABCDE)?
A- asymmetry (not regularly found oval, two halves of lesion do not look the same)
B- border irregularity (notching, scalloping, ragged edges, poorly defined margins)
C- color variation (areas of brown, tan, black, blue, red, white, or combination)
D- diameter greater than 6 mm
E- elevation or enlargement
74
.What is the normal angle of the nailbeds and how are they affected by chronic lung disease, such as emphysema? What finding related to the nails is commonly associated with chronic lung disease?
- 160 degrees
-
normally slightly curved or flat, smooth, rounded & clean
- clubbing is a deformity of the finger or toenails, angle is more than 160 degrees.
- cyanosis or marked pallor nail beds or sluggish color return
75
What is normal capillary refill?
depress the nail edge to blanch and then release, noting the return of color.
less than 1-2 sec
76
what does prolongation suggest?
- vasoconstriction,
- respiratory dysfunction, or
- decreased cardiac output
77
How are tonsils graded and what does each grade mean?
1+ visible "normal in healthy people"
2+ halfway between tonsillar pillars and uvula "normal in healthy people"
3+ touching the uvula
4+ touching each other
78
Describe the procedure for using the otoscope and assessing the nose internally.
- view each nasal cavity with the person's head erect & then with the head tilted back
- inspect nasal mucosa, noting its normal red color & smooth, moist surface
- note any swelling, discharge, bleeding, or foreign body.
- observe septum for deviation
- avoid touching septum with otoscope
79
What is the best technique for palpating lymph nodes? How would a cancerous node feel and appear? How would a node with infection feel and appear?
Start at the preauricular lymph nodes in front of the ear and palpate the 10 groups in routine order. Palpate symmetrically with gentle pressure
80
Which sinuses are accessible to examination and how are they assessed?
Frontal- in the frontal bone above and medial to the orbitis (pressing up & under the eyebrows)
Maxillary- in the maxilla (cheekbones) along the side walls of the nasal cavity (pressing below cheek bones) person should feel firm pressure with no pain
81
Epistaxis
nose bleeds; occurs with trauma, vigorous nose blowing, & foreign body
82
Rhinorrhea
thin, watery discharge from the nose; occurs with colds, allergies, sinus infection & trauma
83
Purulent nasal discharge
thick, yellow, and green discharge; sign of infection
84
Boogers
mucous, dirt, and debris that are collected in your nose so they do not go to the lungs
85
At what site is oral cancer most likely to first appear? Be real specific.
U-shaped area under the tongue behind the teeth.
| Occurs particularly at sides, base, and under tongue. Can be white patches, nodules, or ulcerations.
86
Tension headache
- Headache of musculoskeletal origin, less disabling form of a migraine.
- Usually both sides, across frontal, temporal, and or occipital region of the head
- Bandlike tightness, viselike, nonthrobbing, nonpulsatile
- Gradual onset, last 30 minutes to days
- Mild to moderate pain
- Situational in response to overwork, posture
- Stress, anxiety, depression, poor posture and not worsened by physical activity
87
Migraine headache
- HA of genetically transmitted vascular origin. Plus prodrome, aura, other symptoms
- Commonly one sided but may occur on both sides. Pain is often behind the eyes, the temples, or forehead.
- Throbbing, pulsating
- Rapid onset, peaks 1-2 hours, last 4-72 hours, sometimes longer
- Moderate to severe pain.
- Hormonal fluctuations (premenstrual), foods, hunger, letdown after stress, sleep deprivation, sensory stimuli, changes in weather, physical activity.
88
Cluster headache
- HA that is intermittent, excruciating, unilateral with autonomic signs
- Always one sided. Often behind or around the eyes, temple, forehead, cheek
- Continuous burning, piercing, excruciating
- Abrupt onset, peaks in minutes, last 45-90 minutes
- Can occur multiple times a day and lasts weeks, severe stabbing pain
- Exacerbated by alcohol, stress, daytime napping, wind, or heat exposure
89
Corneal light reflex/Hirshberg test
- assesses the parallel alignment of the eye axes by shining the light toward the person's eye.
- Direct the person to stare straight ahead as you hold the light about 30 cm away.
- Note the reflection of the light on the cornea; it should be the same spot in both corneas.
90
Confrontation test
- measure of peripheral vision. It compares the person's peripheral vision with your own.
- Position yourself eye to eye with patient about 2 feet away. Direct the person to cover one eye with card and look straight at you with the other eye. Slowly advance in from the periphery in several directions, ask the person to say now as the target is first seen this should be when you see it as well
91
Diagnostic position test
- design is to inspect extraocular muscle function.
- Ask person to hold the head steady and follow the movement of your finger with only eyes. Hold about 12 cm away and move in the 6 directions clockwise.
92
What does PERRLA mean?
```
P-pupils
E-equal
R-round
R-react to
L-light
A-accommodation
```
93
What is meant by accommodation and how is it tested?
This is an adaptation of the eye for near vision, and is accomplished by increasing the curvature of the lens through the muscles of the ciliary body. maintain a clear image or focus on an object as distance varies
94
What structures are assessed in the fundoscopic exam and in what order?
```
red reflex
optic disc
retinal vessels
general background
macula
```
95
Presbyopia
- the lens loses elasticity, becoming hard & glasslike.
- decreases the lenses ability to change shape to accommodate for near vision.
- occurs as one ages
96
Myopia
nearsightedness the globe is longer than normal and light rays focus in front of the retina
97
stigmatism
unequal curvatures in different parts of the cornea or lens lead to blurred vision
98
Strabismus
cross eyed. the eye muscles are unable to focus together.
99
Arcus senillis
- a gray-white arc or circle around the limbus; it is due to deposition of lipid material.
- It is a common degenerative change in which the outer edge of the cornea gradually becomes opaque, generally in both eyes, affects people over the age of 50.
100
Cataracts
clouding of lens. Lens opacity, resulting from a clumping of proteins in the lens. Expected by age 70
101
Glaucoma
- an optic nerve neuropathy characterized by loss of peripheral vision, caused by increased intraocular pressure.
- Adults over 40 have this.
102
Macular degeneration
- breakdown of cells in the macula of retina.
- Loss of central vision, the area of clearest vision, most common cause of blindness
- Affects ages 75-85.
- Women are more affected.
- The person is unable to read fine print, sew, or do fine work and may have difficulty distinguishing faces.
- Peripheral vision is not affected.
103
Alien eye test
(2/3 y/o)
| picture cards
104
Snellen E eye test
(3-6 y/o)
| show capital E in varying sizes pointing in different directions
105
Snellen test
(7 y/o-up)
| alphabet chart with 20/20
106
Review what 20/30, 40, 60 etc means.
that the patient can see at 20 feet what a person with normal vision can see 30 feet away from the chart.
107
OU
both eyes
108
OD
right eye (oculus dexter)
109
OS
left eye (oculus sinister)
110
How is the otoscopic exam performed on an adult?
pull pinna up & back
111
How is the otoscopic exam performed on an child
pull pinna straight down; child under 3
112
What are the landmarks which should be identified during the otoscopic exam?
External canal & tympanic membrane
113
What is the procedure for testing auditory acuity?
Whispered voice test
- Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in & out of auditory meatus
- Shield your lips so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using the "good" ear
- With your head 30 -60 cm (1-2 ft) from persons ear, exhale & whisper slowly some two-syllable words
- Normally, a person repeats each word correctly after you say it
114
Presbycusis
age related hearing loss
115
Otosclerosis
- disorder causing progressive deafness due to overgrowth of bone around stapes in the inner ear.
- common cause of conductive hearing loss in young adults between ages 20-40 years.
116
Acute otitis media
This results when the middle ear fluid is infected
| Redness and bulging along with earache and fever
117
Otitis externa
Severe swelling of canal, inflammation, tenderness
| Canal lumen is narrowed to one fourth normal size
118
Otitis media with effusion
- An amber yellow drum suggests serum in middle ear that transudes to relieve negative pressure from the blocked Eustachian tube
- Feeling of fullness, transient hearing loss, popping sound with swallowing
119
Perforation
Drum rupture from increased pressure or trauma
| Appears as a round or oval darkened area on the drum
120
Excessive cerumen
Produced or impacted because of narrow, tortuous canal or poor cleaning method.
May show as round bell partially obscuring drum or totally occluding canal.
121
benign breast disease
Multiple tender masses that occur with:
swelling & tenderness (cyclic discomfort)
mastalgia (severe pain, both cyclic & noncyclic)
nodularity (significant lumpiness)
dominant lumps (cysts & fibroadenoma)
nipple discharge
infections & inflammation
nodularity occurs bilaterally; regular, firm nodules are mobile, well demarcated, & feel rubbery.
pain may be dull, heavy, & cyclic as nodules enlarge.
cysts are discrete, fluid-filled sacs
nodularity is not premalignant but produces difficulty in detecting other cancerous lumps
122
fibroadenoma
Benign tumors; most commonly present as self-detected in late adolescence.
Solitary nontender mass that is solid, firm, rubbery, & elastic. Round, oval, or lobulated; 1 to 5 cm.
Freely movable, slippery; fingers slide it easily through tissue
Usually no axillary lymphadenopathy.
Diagnose by triple test (palpation, ultrasound, & needle biopsy)
123
Breast Cancer
solitary, unilateral, nontender mass.
solid, hard, dense, & fixed to underlying tissues or skin as cancer becomes invasive. Borders are irregular & poorly delineated.
grows constantly. often painless
-most common in upper outer quadrant
124
In which part of the breast are most malignancies found in women? In men?
Women: upper outer quadrant; which contains the axillary tail of spence
Men: usually under the nipple
125
When is the best time of the month for women to do BSE (Breast Self-Exam) and why?
Right after menstrual period (day 4-7 of the cycle) when the breast are smallest and least congested
If they don't have a menstrual period chose a familiar date as a reminder (such as 1st of the month)
126
How is the female client positioned for inspection of the breast and palpation of the breast?
Inspection- the woman is sitting up, facing the examiner
| Palpation- woman is in supine position
127
What is the procedure for screening women for nipple and skin retraction during a breast exam?
- Lift arms over head; upward movement symmetrically
- Inspect with hands on hips
- Inspect with palms pushed together
128
What is the procedure for assessing the lungs and thorax?
inspect, palpate, percuss, and auscultate
129
Bronchial
louder and higher pitch (inspiration is shorter); louder and higher in pitch; usually heard over the manubrium (Trachea, Larynx)
130
Bonchovesicular
medium pitch (inspiration = expiration); usually heard over the 1st and 2nd interspaces (Upper Sternum, Scapula)
131
Vesicular
soft, low pitched (inspiration is longer); usually heard over most of both lungs (peripheral lung fields)
132
What percussion note would the nurse expect to hear over normal lung tissue in a healthy adult?
Resonance is normal for adult
133
What percussion note would the nurse expect to hear over lungs with emphysema, pneumothorax,
child’s lung
Hyperresonance
134
What percussion note would the nurse expect to hear over the lungs of a patient with chronic obstructive pulmonary disease (COPD) such as emphysema?
hyperresonance (lower-pitched booming sound found when too much air is present)
135
What percussion note would the nurse expect to hear over the lungs of a patient with chronic obstructive pulmonary disease (COPD) such as Pneumonia?
dull note (soft, muffled thud) signals abnormal, pleural effusion, atelectasis, or tumor
136
Wheezes
continuous musical snoring, moaning sounds. predominate in expiration but may occur in both expiration & inspiration
high pitched: acute asthma, emphysema
low pitched: bronchitis
137
Pleural friction rubs
a very superficial sound that is coarse & low pitched, it has a grating quality as if two pieces of leather are being rubbed together (pleuritis)
138
Coarse rhonchi
loud, low-pitched bubbling and gurgling sound that start in early inspiration & may be present in expiration (Pneumonia, pulmonary edema)
139
Crackles
fine: discontinuous, high-pitched, short crackling popping sounds heard during early inspiration that are not cleared by coughing
late inspiratory crackles occur with restrictive disease (pneumonia, heart failure)
early inspiratory crackles occur with obstructive disease: (chronic bronchitis, asthma, emphysema)
140
PND (Paroxysmal nocturnal dyspnea)
shortness of breath that awakens the patient in the middle of the night; usually relieve in the upright position
141
Orthopnea
trouble breathing while lying down; relieved by sitting or standing
142
What is the sequence for assessing the abdomen
Inspection
Auscultation
Percussion
palpation
143
What percussion sound is heard over the liver?
dullness
144
What instructions are given to the patient prior to starting the abdominal exam?
```
Patient should empty the bladder
Lay in supine position, flexing knees
Arms at their sides
Pillow under knees
Expose abdomen as much as you can
```
145
What is the most predominant percussion sound heard over the abdomen?
Tympany
146
quadrant of the liver
right upper quadrant
147
quadrant of the spleen
Left upper quadrant
148
quadrant of the appendix
Right lower quadrant
149
quadrant of the kidneys
right kidney- right upper quadrant
| left kidney- left upper quadrant
150
Rebound tenderness (Blumberg sign)
Choose a site away from the painful area.
Hold your hand 90 degrees (perpendicular) to the abdomen.
Push down slowly & deeply then lift up quickly
pain on release of pressure confirms rebound tenderness, which is a sign of peritoneal inflammation & appendicitis
151
Inspiratory Arrest (Murphy Sign)
Normally palpating the liver causes no pain. In a person with inflammation of the gallbladder (cholecystitis), pain occurs.
Hold your fingers under the liver border.
Ask the person to take a deep breath. A normal response is to complete the deep breath without pain.
152
Fluid wave test
Stand on the person's right side.
Place the ulnar edge of another examiner's hand or the patient's own hand firmly on the abdomen in the midline.
Place your left hand on the person's right flank. With your right hand, reach across the abdomen & give the left flank a firm strike
If ascites is present, the blow will generate a fluid wave through the abdomen
A positive fluid wave test occurs with large amounts of ascitic fluid
153
Iliopsoas Muscle test
Perform when the acute abdominal pain of appendicitis is suspected.
With the person supine, lift the right leg up, flexing at the hip; then push down over the lower part of the right thigh as the person tries to hold the leg up.
When the test is negative, the person feels no change.
154
Normoactive bowel sounds
indicating normal activity. High pitched, gurgling, cascading sounds, occurring irregularly 5 to 30 times per minute.
155
Hyperactive bowel sounds
loud, high pitched, rushing, tinkling sounds that signal increased motility. >35
156
Hypoactive or absent bowel sounds
follow abdominal surgery or with inflammation of the peritoneum. <5
157
How long do you have to count to determine that bowel sounds are really absent?
The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent
158
What topics are important to include when teaching someone about hepatitis prevention and liver health?
```
practice safe sex
watch diet & weight
travel wisely
use medications wisely
drink in moderation
don't mix medications & alcohol
no illegal drugs
vaccinations are available for Hep A & B
```
159
What is the sequence of steps in an examination of all joints and muscles in the MS system?
Inspection
Palpation
Range of Motion
Muscle Strength
160
How is muscle strength recorded? Know what the patient’s response is to each grade (0/5, 1/5, 2/5, 3/5, 4/5, 5/5).
0 to 5 Rating Scale for Muscle Strength
0/5: No contraction.
1/5: Some but virtually no contraction of the muscle, and not enough strength to move it. Trace.
2/5: Voluntary movement with passive ROM. For example, the patient would be able to slide their hand across a table but not lift it from the surface. Poor.
3/5: Full ROM with gravity, but incapable of overcoming resistance. For example, the patient could raise their hand off a table, but not if any additional resistance were applied. Fair.
4/5: Voluntary movement capable of overcoming “some” resistance. Good.
5/5: Full ROM against gravity, full resistance. Normal.
161
Rheumatoid arthritis
chronic inflammatory pain condition that is possibly started by an autoimmune response, inflammatory event, or infection.
More women than men affected (30-60 years old)
Inflammation of synovial tissues, hyperplasia, and swelling lead to fibrosis, cartilage and bone destruction, which limit motion and show as deformity
Joint is symmetric and bilateral, with heat, redness, swelling, and painful motion
Symptoms:
Fatigue
Weakness
Anorexia
Weight loss
Low-grade fever
Lymphadenopathy
162
Osteoarthritis
noninflammatory, localized progressive disorder involving deterioration of articular cartilages and subchondral bone remodeling, synovial inflammation, and formation of new bone at joint surfaces
I risk with older age, females, and Caucasians
Asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine
Symptoms
Stiffness
swelling with hard, bony protuberances
pain with motion
limitation of motion
163
What patient complaints or problems would indicate the need to do a screening or a complete musculoskeletal exam?
Joint pain, stiffness, limited motion
Muscle cramps, myalgia, weakness
Bone pain, deformity, trauma
Decline in ADLs
164
Know the tests that are included in a screening neuro exam, a complete neuro exam, and a neuro check in the hospital. Which type of patient conditions would indicate the need for each exam?
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Head trauma
Dizziness or vertigo
Seizures (focal, generalized): 4 phases - aura, tonic, clonic, postictal
Tremors – rest and intention
Weakness - paresis
Gait incoordination - ataxia
Numbness or tingling - paresthesia
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165
CN I Olfactory
Occlude each nostril and test different smells
166
CN II Optic
Test visual acuity with Snellen eye chart or hand-held card; inspect fundi; screen visual fields by confrontation
167
CN II-III Optic, Oculomotor
Inspect size and shape of pupils; test reactions to light and near response (PERRLA)
168
CN III, IV, VI Oculomotor Trochlear, Abducens
Test extraocular movements in 6 cardinal directions of gaze; lid elevation; check convergence
169
CN V Trigeminal
Palpate temporal and masseter muscles while patient clenches teeth; test forehead, each cheek, and jaw on each side (3 places) for sharp or dull sensation; test corneal reflex
170
CN VII Facial
Assess face for asymmetry, tics, abnormal movements. Ask patient to raise eyebrows, frown, close eyes tightly, show teeth (grimace), smile, puff both cheeks
171
CN VIII Acoustic
Test hearing, lateralization, and air and bone conduction. Whisper test.
172
CN IX and X Glossopharyngeal, Vagus
Assess if voice is hoarse; assess swallowing. Inspect movement of palate as patient says “ah.” Test gag reflex, warning patient first.
173
CN XI Spinal Accessory
Assess strength as patient shrugs shoulders up against your hands. Note contraction of opposite sternocleidomastoid, and force as patient turns head against your hands.
174
CN XII Hypoglossal
Ask patient to protrude tongue and move it side to side. Assess for symmetry, atrophy.
175
How is cerebellar function tested?
Assess Motor Function
(Cerebellar)
Balance
Gait - Tandem Walking
Romberg Test
176
How is coordination of the extremities tested?
Assess Motor Function
(Coordination and Skilled Movement)
Rapid Alternating Movements (RAM)
Finger-to-Finger/Finger-to-Nose
Heel-to-Shin
177
What instruction to the client is essential when testing sensory perceptions?
Avoid asking leading questions: Can you feel the pinprick?
| DO ask unbiased question: Tell me what you feel.
178
How are DTRs (deep tendon reflexes) graded (0-4+) and be able to interpret each grade.
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4+ Very brisk, **clonus
3+ Brisker than average
2+ NORMAL
1+ Diminished
0 No response
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179
Review how to test the plantar reflex in adults. What would be the finding associated with an abnormal plantar (Babinski) reflex in adults and children?
Plantar reflex: position the thigh in slight external rotation. With the reflex hammer, draw a slow stroke up the lateral side of the slow of the foot and inward across the ball of the foot, like an upside -down J.
Normal response is plantar flexion of the toes and inversion and flexion of the forefoot
Abnormal response is the dorsiflexion of the big toe and fanning of all toes which is a positive Babinski sign. This occurs with UMN disease of the corticospinal (or pyramidal tract) tract, accompanied by foot weakness.
Babinski is present at birth and disappears by 2 years of age.
180
Review how to perform the Romberg test
Romberg test: ask the person to stand up with feet together and arms on the side. Once in stable position, ask him or her to close the eyes and to hold position for 20 seconds.
181
What are the findings of a positive Romberg and a negative Romberg?
Normal response is a person can maintain posture and balance even with the visual orienting information blocked
Positive Romberg sign is a los of balance that occurs when closing the eyes. It occurs with cerebellar ataxia (MS, alcohol intoxication), loss of proprioception, and lose of vestibular function.
182
Stereognosis
ability to identify a familiar object on the hands by exploring with fingers and correctly naming it
183
Graphesthesia
ability to read a number by having it traced on the skin
184
What are normal findings of the male genitalia in adulthood and advancing age?
- Pubic hair white and thinner
- Testes decrease in size, firmness, lower
- Prostate hypertrophies
- Penis decreases in size, sensation
- Scrotum more pendulous
185
Hypospadias
- urethral meatus opens on the ventral (under) side of the glans or shaft
- Congenital that can be corrected with surgery
186
Epispadias
- meatus opens on the dorsal (upper) side of glans or shaft above a broad, spade like penis.
- Rare; less common than hypospadias but more disabling because of urinary incontinence and separation of pubic bones
187
Phimosis
- nonretractable foreskin forming a pointy tip with a tiny orifice. Foreskin is advanced and so tight that it is impossible to retract over glans.
- Maybe congenital or acquired from adhesion secondary to infection
- Poor hygiene leads to retained dirt and smegma increasing the risk for inflammation, calculus formation, obstructive uropathy
188
Hydrocele
- cystic collection of serous fluid in the tunica vaginalis, surrounding the testis
- Appears as a large scrotum and transilluminates as a faint pink glow.
- Disappears spontaneously
189
Cryptorchidism
- undescended testes (those that never descended).
| - Common in premature infants
190
When and how is Testicular Self Examination performed?
-Monthly exam age 13-40 years
-Perform during shower
-Use thumb and first two fingers
-Points to include during health teaching are:
T - timing, once a month
S - shower, warm water relaxes scrotal sac
E - examine, check for and report changes immediately
-Report hard non-tender mass and any changes
191
What population of men (by age) is at the highest risk for testicular cancer?
- Between 15 and 35 years of age
| - Associated with history of cryptorchidism and other factors
192
Urge incontinence
involuntary urine loss from overactive detrusor muscle in the bladder
193
Stress incontinence
involuntary urine loss with physical strain, sneezing, or coughing caused by weakness of pelvic floor
194
Overflow incontinence
unable to empty the bladder
195
Know the normal female genital findings found in Infants and Children
- At birth, external genitalia are engorged because of presence of maternal estrogen
- Structures recede in a few weeks, small until puberty
- Ovaries located in abdomen during childhood
- Uterus small with a straight axis and no anteflexion
196
Know the normal female genital findings found in Changes with Aging
- Menopause: cessation of menses
- Usually this occurs around 48 to 51, although a wide variation of ages from 35 to 60 years exists
- Stage of menopause includes preceding 1 to 2 years of decline in ovarian function, shown by irregular menses that gradually become farther apart and produce lighter flow
- Ovaries stop producing progesterone and estrogen
- Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes
- Uterus shrinks in size
- Ovaries atrophy to 1 to 2 cm and are not palpable after menopause
- Ovulation still may occur sporadically after menopause
- Uterus droops as sacral ligaments relax and pelvic musculature weakens
- Sometimes it may protrude, or prolapse, into vagina
- Cervix shrinks, looks paler, thick, glistening epithelium
- Externally, mons pubis looks smaller because fat pad atrophies
- Labia and clitoris gradually decrease in size
- Pubic hair becomes thin and sparse
- Pendulous breasts
197
What questions are important to ask when someone presents with a complaint of vaginal discharge?
Color, amount, & consistency
198
What is the structure that is visualized when an internal pelvic exam is done?
Cervix and it’s Os
- Color: normal cervical mucosa is pink; blue on the 2nd month of pregnancy; pale after menopause
- Position: midline, either anterior or posterior; projects 1-3 cm into the vagina
- Size: 2.5 cm diameter
- Os is a small and round in the nulliparous woman
199
Amenorrhea
absent menses
200
Dysmenorrhea
painful menses
201
Menorrhagia
increase amount of bleeding; heavy menses
202
Polymenorrhea
frequent menses cycle
203
Metorrhagia
bleeding within periods (spotting)
204
Menopause
cassation of menstruation
205
Papanicolaou test
an exam that is used to detect cervical cancer and precancerous conditions of the cervix
206
Adnexa
of the uterus is the space in your body occupied by the uterus.
207
vulva
outer part of female genitals
208
Gravida
number of pregnancies
209
Para
number of births
210
Abortion
interrupted pregnancies, including elective abortions and spontaneous miscarriages
