Lab Final Flashcards
(192 cards)
1
Q
Location breasts on chest wall, axillary tail of spensce, nipple and areola
A
Surface Anatomy Breasts
2
Q
Glandular Tissue: Lobes, lobules, alveoli. lactiferous ducts aand sinuses
- Fibrous tissue - Suspensory ligaments or cooper`s ligaments - Adipose Tissue
A
Internal Anatomy Breasts
3
Q
Breast: Pain, lump, disharge, rash, swelling, trauma
- History breast Disease
- Surgery
- Self-care behaviours
A
Breast subjective data
4
Q
Axilla: tenderness, lump or swelling, rash
A
breast subjective data
5
Q
General appearance of breasts. skin, lymphatic drainage areras, nipples
A
Objeftive Data
6
Q
Axillae - inspect and palpate. -skin, palpation technique, lymph nodes
A
Objective Data
7
Q
Location, size, shape, consistency, mobility, distinctness, nipple retraction, overlying skin, tenderness, lymphadenopathy.
A
Presence of a lump in breast
8
Q
corpora cavernosa, corpora sponginosum, glans, corona, urethra, foreskin
A
Penis
9
Q
Rugae, Vas deferens, cremaster muscle, spermatic cord. testis, ejaculatory duct, epididymis
A
Male Genitourinary Assessment
10
Q
Frequency, urgency nocturia. Dysuria, hesitancy and straining, urine colour
A
M Genitourinary Subjective Data
11
Q
History. Penis - pain, lesion, and or discharge.
Scrotom-self-care behaviours, lump
Sexual activity, contraceptive use, std contact
A
M Genitourinary Subjective Data
12
Q
Inspect and Palpate - Skin, glans, urethral meatus, pubic hair, urethral discharge, shaft
A
Penis objective data
13
Q
Inspect and palpate - skin, testes, epididymis, spermatic cord, any mass (characteristics, transillumination)
A
Scrotom objective data
14
Q
Check for hernia (person standing and strainning down) and check ingenial lymphnodes
A
Objecrive Data
15
Q
Start early 13-14 yoa. performed every month
A
Testicular Self Exam
16
Q
T = time S = Shower E = Examination points
A
-once a month - shower/bath = examine, check for changes, report changes immediately
17
Q
Gland can grow after 40 and is a normal part of aging. called benign _____ hypertrophy
A
Prostate Screening
18
Q
4 basic exam modes
A
inspection, palpation, percussion, auscultation.
19
Q
Determines ares to focus on in physical examination and symptom/sign analysis
A
Subjective data
20
Q
Observable action or physical manifestation
A
Sign
21
Q
Sensations or emotions by a client, unobservable and not always verifyable
A
Symptoms
22
Q
Indicators of client’s circulatory, respiratory, endocrine and neural functions. Any changges indicate alterations in physiological functioning
A
Vital Signs
23
Q
BP, Heart rate and rhythm, respirations, o2 sat, temp
A
Vital Signs
24
Q
“fifth vital sign”
A
Pain
25
Located anterior to pectoralis major and serratus anterior muscles
Breasts
26
Extend from sternum - mid exillary line and from clavicle and second rib to the sixth rib
Breasts
27
Round in shape, situated slightly below center of breast. usually protuberant and surface may be smooth or wrinkled
Nipple
28
Surrounds nipple (round or oval)
Areola
29
Large portion drains into axillary lymph nodes
Lymph from breasts
30
Located along chest wall and high up in the axillae
Central nodes
31
Drain in to the central nodes (3)
Pectoral, subscapular, cateral lymph nodes
32
Performed monthly
BSE
33
Annually
Breast exam by HCP
34
Every 2 years (50-69)
Mammograms
35
Use fingerpads in a correct circular fashion. Best time 7 days before start of menstrual period.
BSE
36
Most effective intervention of problems with skin integrity
Prevention
37
2 initial defences precenting skin breakdown.
Asessment and Skin Hygeine
38
Avoid soap and hot water, use cleansers with noonionic surfactants
Skin breakdown prevention
39
Goal of effective wound management
Maintainance of a physiological local wound environment
40
Prevent and manage infection, cleanse wound. remove non viable tissue, manage exudate, moist environment, protect wound
needed to maintain healthy wound environment
41
Wound irrigation, cleaning, and removing nonviable tissue
Prevent infection
42
Use only noncytotoxic wound cleansers eg. Saline.
Cleaning a wound
43
Removal nonviable, necrotic tissue
Debridement
44
Functions of Debridement (3)
Rids ulcer from a source of infection, enable visualization wound bed, provide clean base for healing.
45
Shear, Friction, pressure, moisture
Causative factors pressure ulcers
46
Protects wound microorganism contamination, aids homeostasis, promotes healing by absorbing drainage and support autocytic debridement.
Purposes of dressings
47
Supports or splints wound site, protects client from seeing wound, promotes thermal insulation, provides moist environment.
Purposes of dressings
48
Breast composed of (3)
Glandular tissue, fibrous tissue including suspensory ligaments, adipose tissue
49
15-20 lobes radiating from nipple
Glandular tissue
50
Suspensory breast ligaments
Cooper`s ligaments
51
Breast quadrants (4)
Upper inner quad, upper outer quar, lower inner quar, lower outer quad. Tail of spense
52
Redness, Bulging or Dimpling
Objective Data
53
Medications, Exposure to readiation, mouth breathing
Impair salivary secretion
54
Hx of skin disease, change skin colour, pigmentation, bruising, dryness, hair, nails etc.
Integument Subjective data
55
Inspect and Palpate: Skin: colour, temp, moisture, texture, thickness, edema, mobility/turgor, vascularity, lesions
Integument Objective Data
56
Inspect and palpate:Hair: Colour, texture, distribution, lesions. Nails: shape/contour, consistency, colour
Integument Objective Data
57
Dry skin, acne, skin raches, contact dermititis, psuriasis, abrasions
Common skin problems
58
Callus, corns, plantar warts, tinea pedis (athletes foot), ingrown nails, ram's horn nails, paranychia, odours
Common foot and nail problems
59
Dandruff, Ticks, lice, alopecia
Common hair and scalp problems
60
Skin loses elasticity and moisture and sebaceous and sweat glands become less active, epiphelium things and elastice collagen fibres srink in the..
Older adult`
61
Body's largest organ system
Skin
62
Protection, prevents penetration, perception, temp regulation, identification, communication, wound repair, absorption and excretion, production vitamin D
Skin functions
63
History Skin disease, change in pigmentation, change in mole, excessive dryness or moisture, Excessive bruising, rash or lesion, medications, hair loss, change in nails, environmental or occupational haards, self care beahviors
Skin Subjective data
64
Integrated throughout complete examination
Skin assessment
65
Inspect and palpate skin: Colour, general pigmentation, pallor (white), erythema (red), cyanosis (blue) and juandic (yellow)
Objective data
66
Skin warm temp =
normal circulatory status
67
Inspect and palpage: Moisture, edema, texture, mobiiity and turgor, thickness, vascularity or bruising, lesions
Objective data
68
Emotional and cognitive thinking
Mental Status
69
Organis Disorder or psychiatric mental illness
Mental Disorder
70
Inferred through individualès behaviours
Mental Status
71
Consciousnesss, Orientation, language, attention, mood and affect, memory, abstract reasoning, though process, thought content, perceptions
Mental Status
72
When Perform Full mental status Exam? (4)
behaviour changes, brain lesions (trauma, tumor, brain attack), Aphasia (cause by brain damage), Symptoms psychiatric mental illness
73
Known Illness or problem. - current medication known affect mood/cognition. - baseline educational - behavioural level - Personal history (stress, social habits, sleep habite, drug and alcohol use)
Health History
74
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B
C
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Main components of a mental status exam:
Appearance
Behaviour
Cognition
Thought Processes
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75
Posture, body movements, dress, grooming and hygeine
Appearance
76
LOC, facial expression, speech, mood and affect
Behaviour
77
Orientation, attention span, recent memory, remote memory, new learning (the four unrelated words), Judgement
Cognitive functions
78
Orientation, registration, attention, calculation, recall, language
Minimental state
79
Outer layer of eye
Sclera
80
Choroid 0 Ciliary body and iris, pupil, lens, anteroir chamber
Middle layer of eye
81
Inner layer (4)
-Retina, Optic Disc, Retinal vessels, macula
82
Papillary Light reflexes, fixation, accomodation
Visual Reflexes
83
Age and Changes in vision (4)
Presbyopia, cataracts, glaucoma, macular degeneration
84
Vision difficulty, pain, redness, swelling, drynesss, discharge, injury, past surgery, eye care, glasses, contact lenses.
Eyes - subjective data
85
Inspect: General, eyelids, lashes, eyeballs, conjunctiva, sclera, cornea, lens, iris pupil (size and shape, pupillary light reflex, accomodation)
Eyes - objective data
86
External auditory canal, tymphatic membrane
External Ear
87
Macleus, incus, stapes. Eustachian tube
Middle Ear
88
Vestibule, semicircular canals, cochhlea
Inner Ear
89
Pathways of hearing (2)
Air conduction, bone conduction
90
earaches, infections, hearing loss, enviro noise, discharge, tinnitus, vertigo, self care behaviours, Aids
Ears Subjective data
91
Inspection : Pinna, external auditory canal. Whisper test. Tuning fork (rinnel test, weber test)
Ears objective data
92
Sensory deficit
Sensory deprivation
Sensory overload
sensory alterations
93
Headache, head injury, dizziness/vertigo, seizures, tremors, weakness, incoordination. numbness or tingling, difficulty swallowing, difficulty speaking, significant history, environmental.occupational hazards
Neurological Subjective data
94
Motor system - inspect and palpate, musscles: size, strength, tone, involuntary movements
Neuro obj data
95
Cerebeluar function - balance tests: gait
Neuro obj data
96
LOC
Level of consciousness person place time
97
Motor function, LOC, papillary response, vital signs, glasgow coma scale
Neuro objective data
98
Good standard assessment LOC
-arousal and awake systems, reflects best response
divided 3 subscales (eye opening, best verbal response, best motor response)
15 = fully oriented. <7 = coma
Glasgow coma scale (GCS)
99
Persistent vegitative state, locked-in syndrome, light to deep coma states
Full alertness - deep coma
100
Progression through cognitive states is
Individual
101
Assess speech quality and patterns, look for delays in response, note tongue movement or facial droop, vary questions
Assessing verbal responses
102
Decrease in loc, new or increasing deficits, unusually high/low bp, irregular heart rhythms, increased temp, seizure activity
Reportable findings
103
The relationship of one body part to another along a horizontal/vertical line.
Body Alignment
104
Acheived with a relatively low centre of gravity
Body Balance
105
Bones, joints, ligaments, tendons, cartilage
Skeletal system
106
Kind and amount of activity one is able to perform
Activity tolerance
107
Cause muscle contraction and change in muscle length (eg. walking, jogging, or swimming)
Isotonic exercises
108
Tightening and holding muscles for a number of second in stationary position
Isometric exercises
109
Contract muscle while pushing against a stationary/resistant object
Resistive isometric exercises
110
Muscles must pull in opposite dircetion to counteract the force of gravity
Posture
111
Coordinated by the nervous system to maintain posture and initiate movement
Muscle groups
112
Contract to accomplish same mobement (eg flex arm)
Syngergistic
113
Joint stabilization opposing effect of gravity
Antigravity
114
Movement, posture, muscle groups, proprioception (awareness of the poition of the body/body parts), balance (controlle specifically by cerebellum and inner ear)
Nervous system (regulation of movement)
115
Affect msk alignment, balance, appearance (eg. scollosis - curvature of the spine and vertebral rotation)
Congenial Defects
116
Disorders of bones, joints and muscles (osteoporosis, arthritis)
central nervous system damage - Rt sid CVA = Lt sided hemiplegia.
Musculoskeletal trauma
congenial defects
Pathological Influences (movement)
117
Developmental changes in appearance and function
Infants through school age children, adolescents, young to middle adults, older adults.
118
Body Mechanics Assessment (4)
Body alignment & posture
Mobility
Activity tolerance
Client expectations
119
Standing - Head erect, body midline, symmetry of body parts, spine straight with normal curvature
Sitting - Head,Neck, Vertebral columb in straight alignment, symmetry, body weight evenly distributed
Recumbent position - Supine w/ one pillow
Body Allignment and Posture assessment
120
ROM - determine degree damage, injury to a joint
Gait- rhythm, cadence (walking rate; steps/minute), speed
Exercise - physical activity ; fitness, types of exercise
Mobility assessment
121
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Activity intolerance
Disturbed body image
Risk for injury
Impaired physical mobility
Acute/Chronic pain
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Nursing Diagnosis
122
Implementation
Health promotion
| Nursing safety
123
Body mechanics - coordinated efforts of the MSK and NS to maintain balance, posture and body alignment when lifting, bending, moving and performing ADL's.
Body mechanics
124
Ensure safety and well being for nurse and client using good
Body mechanics
125
Inability to move about freely
Immobility
126
Endocrine, calcium absorption and GI function
Metabolic effect on immobility
127
Atetectasis and hypostatic pneumonia
Respiratory effect on immobility
128
Orthostatic Hypotension, thrombus
Cardiovascular Effects on immobility
129
Loss of endurance and muscle mass and decreased stability and balance
Musculoskeleteal changes (effect on immobility)
130
loss of muscle mass, muscle atrophy
muscle effects on immobility
131
Impaired calcium absorption and joint abnormalities.
Skeletal effects on immobility
132
Urinary stasis, renal calculi
Urinary elimination effects on immobility
133
Pressure ulcer, ischemia
Integumentary effects on immobility
134
Hostility, Giddiness, Fear, Anxiety
Emotional and behavioural responses to immobility
135
Sleep-wake alterations
sensory alterations in immobility
136
Depression, Sadness, Dejection
Coping effects of immobility
137
Nonsynovial (skull) or synovial (knee)
Joints
138
Fibrous band from one bone to another
Ligament
139
Fluid-filled sac, prevents friction on joints
Bursa
140
Bundles of muscle fibres
Fasciculi
141
Attaches muscle to bone
Tendon
142
Joints (painm stiffness, swellinng/heat/redness, limitations)
Subjective data
143
Muscles (pain.cramps weakness)
Subjective data
144
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Pain, deformity, trauma - fractures, strains, dislocations)
Functional assessment (ADLs)
Self-care behaviours
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Subjective data
145
The physical exam - inspection (size, contour of joint, skin) - Palpation (joints, muscles - tenderness, heat, swelling, masses
- ROM
- muscle testing
Objective data
146
The science of health and it's maintenance
Hygeine
147
Self care by which people attend to such funtions as bathing, toileting, general bodoy hygeine and grooming
Personal hygeine
148
Highly personal matter determined by individual values and practises.
Hygeine
149
Involves care of skin, hair, nails, teeth, oral and nasal cavities, eyes, ears, perineal area.
Hygeine
150
Affects individual's comfort, safety and physical and psychological well-being
Hygeine
151
Require special attention to prevent infection
Feet, hands, and nails
152
Social patterns, personal preference, oody image, socio-economic status, health beliefs and motivation, cultural variables
Factors influencing hygeine.
153
Complete bed bath, Partial bed bath, tub bath or shower, bag bath, therapeutic baths, sitz baths
Bathing types
154
Provide privacy, maintain safety, maintain warmth, promtote independence, anticipate needs.
Bathing guidelines
155
Careful inspection, lukewarm water temp, no soaking, cutting of nails if indicated, application of lotions, proper socks, stockings and shoes.
Foot and nailcare guidelines
156
Inspect all skin surfaces (toes, cleanliness, odour, dryness, inflammation, swelling, abrasions)
Foot care
157
Palpate anterior and postrior surfaces of ankles and feet for edema
Foot care
158
Palpate dorsalis pedis and posterior tibial pulse
Foot care
159
Compare skin temp on both feet, assess sensation of touch, assess movement
Foot care
160
Brushing and flossing, denture care
Oral Hygeine
161
Presense stomatitis, use oxygen therapy, unconscoius state
Special needs oral care
162
Skin and mucousal membranes, kidneys, bladder, femalr perineum, male perineum
Physical urinary elimination assessment
163
Colour - pale straw - amber
Clarity - Transparent unless pathology present
Odour - Amonia-like in nature
Urine Assessment
164
Impaired sensory perception, alteration to LOC, Shear, Nutrition, Tissue perfusion, Inspection, pain, friction, moisture
Risk factors for pressure ulcer development
165
Sufficient nutrients consumed to meet day-day body needs
Optimal nutritional status
166
Nutritional reserves depleted and.oor nutrient intake is inadequate to meet day to day needs
Undernutrition
167
Consumption nutrients, especially calories, sodium and fat in excess of body needs, risk for obesity.
Overnutrition
168
Poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty
Nutritional risk factors of tthe aging adult
169
To identify individuals who are malnourished or at risk of developing malnutrition.
Purpose of nutritional assessment
170
Admission nutrition screening tool, 24-hour diet recall, Food frequency questionnaire, food diaries, direct observation.
Nutrition screening.
171
Eating patterns, usual weight, changes in appetite, taste, smell, chewing, swallowing, recent surgery, trauma, burns, infection
Nutrition subjective data
172
Chronic illnesses, vomiting, diarrhea, constipation
food allergies or intolerances
Medications and/or nutritional supplements.
Nutrition subjective data
173
Self care behaviours, alcohol or illegal drug use, exercise and activity patterns, family history.
Nutrition subjective data
174
Body weight as percent of ideal body weight,
percent usual body weight
recent weight change
Derived body measures
175
BMI = Weight kg/height m2
Body mass index
176
Waist to hip ratio
Waste circumference/hip circumference
177
Hemoglobin, hematocrit, cholesterol, triglycerides, total lymphocyte count, skin testing, serum proteins, nitrogen balance, creatine-height index
Lab studies in nutritional assessment
178
Four quadrants of the abdominal wall.
Right upper
Left upper
right lower
left lower
179
3 regional areas
epigastric
umbilical
hyogastric/suprapubic
180
Liver, gallbladder, duodenum, head of pancreas, RT kidney, hepatic flexure of colon, part of ascending and transverse colon.
RUQ
181
Stomach, spleen, L lobe of liver, body of pancreas, Lt kidney and adrenal, splenic flexure of colon, part of transverse and descending colon.
LUQ
182
Celum, appendix, rt ovary and tube, rt ureter tube, ty spermatic cord
RLQ
183
Part of descending colon, sigmoid colon, lt ovary and tube, lt ureter, lt spermatic cord.
LLQ
184
Appetite, dysphagia, food intolerance, abdominal pain. nausea/vomiting, bowel habits, abdominal history, meds, nutritional assessment
Subjective data
185
Inspect abdomen: contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, demeanor.
Objective data
186
Auscultate the abdomen - bowel sounds and vascular sounds (bruits)
Objective data
187
Percuss abdomen, general tympany, liver span - usual technique, scratch test
- splenic dullness, costovertebral angle tenderness
- Special procedures: fluid wave and shifting dullness
- Palpate liver
Objective data
188
religion, cultural background, ethics, health beliefs, preference can be influences of
alternative food patterns
189
Four vegetarian diets
-ovolactovegetarian, lactovegetarian, vegans, fruitarian
190
Anthropometry, BMI, Ideal body weight, lab/biofhemical tests, dietary history, health history, clinical observations, client expectations, health assessment
Abdominal assessment
191
Risk for aspiration, constipation, diarrhea, inbalanced nutrition, feeding self-care deficit
Nursing Diagnosis
192
Advancing diets, promoting appetite, assisting with feeding, external tube feeding, parenteral nutrition.
Implimenting nutrition in acute care
