MIDTERM Flashcards
(152 cards)
1
Q
what the person says about himself or herself during history taking
A
SUBJECTIVE DATA
2
Q
what you as the healthcare professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
A
OBJECTIVE DATA
3
Q
HOW TO VALIDATE DATA
A
validating or checking the accuracy and reliability of data
EG. in addictions treatment, a clinician will corroborate data with a family member or friend in order to verify the accuracy of Ellen’s history
4
Q
NURSING PROCESS
A
- assessment
- diagnosis
- outcome identification
- planning
- implementation
- evaluation
5
Q
4 TYPES OF DATA
A
- COMPLETE DATABASE
- EPISODIC OR PROBLEM-CENTRED DATABASE
- FOLLOW-UP DATABASE
- EMERGENCY DATABASE
6
Q
THIS KIND OF DATA INCLUDES:
- includes a complete health history and full physical examination
- describes the current and past health state and forms a baseline against which all future changes can be measured
- yields the first diagnoses
A
COMPLETE DATA
7
Q
THIS KIND OF DATA INCLUDES:
- collected for limited or short-term problem
- concerns mainly one problem, one cue complex or one body system
A
EPISODIC OR PROBLEM-CENTRED DATA
8
Q
THIS KIND OF DATA INCLUDES:
- status of any identified problems should be evaluated at regular and appropriate intervals:
- what change has occurred?
- is the problem getting better or worse?
- what coping strategies are used?
A
FOLLOW-UP DATA
9
Q
THIS KIND OF DATA INCLUDES:
- calls for rapid collection of the data - often compiled concurrently with life-saving measures
- diagnosis must be swift and sure
- requires more rapid collection of data than the episodic database
A
EMERGENCY DATA
10
Q
DISADVANTAGES OF note taking during an interview
A
DISADVANTAGES
- breaks eye contact too often
- shifts your attention away from the person - diminishes his/her sense of importance
- can interrupt patient’s narrative flow
- impedes your observation of patient’s nonverbal behaviour
- threatening to the patient
11
Q
ADVANTAGES OF note taking during an interview
A
ADVANTAGES
- helps memory
- increases accuracy
- provides interview cues
12
Q
TRUE OR FALSE
interview usually takes longer with older adults
A
TRUE - because they have a longer story to tell
13
Q
TRUE OR FALSE
adolescents know a lot about health assessment and dont need explanations
A
FALSE
14
Q
why is building a rapport with adolescents is essential?
A
because otherwise they might not participate
15
Q
TRUE OR FALSE?
it is important to adjust the pace of the interview to the aging person
A
TRUE -
give them time to remember - do not rush them
16
Q
WHY IS IT IMPORTANT TO AVOID AN abrupt or awkward closing to an interview?
A
can destroy rapport and leave a negative impression
17
Q
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
* egocentric - sees the world mostly from his/her own point of view * everything revolves around them * communication is direct, concrete, literal and set in the present * use simple, short sentences with a concrete explanation
A
preschooler (2-6)
18
Q
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
- can tolerate and understand other perspectives
- more objective and realistic
- wants to know functional aspects - how things work & why things are done
- can verbalize important data to add to history
- pose questions about school, friends or activities
A
school-age child (7-12)
19
Q
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
* fluctuate between mature and childlike responses * value their peers & crave acceptance * think adults don't understand them
A
adolescent (13-19)
20
Q
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
- focused on finding out the meaning of life and the purpose of his/her own existence
- adjusting to inevitability of death
- be aware that symptoms of illness are even more frightening when they mean physical limitation or threaten independence
- always address the person by the last name
A
older adult
21
Q
Reason for seeking care – how to chart
A
- record the patient’s exact words enclosed in quotations
- “Want to start jogging and need checkup.”
22
Q
Questions to ask when someone states they are allergic to a medication
A
- Note both the allergen (medication, food, or contact agent, cushy as fabric or environmental agent) AND the reaction (rash, itching, runny nose, watery eyes, difficulty breathing)
23
Q
Purpose of a functional assessment
A
- functional assessment questions provide data on the lifestyle and type of living environment to which the person is accustomed
24
Q
subjective sensation that the person feels from the disorder
A
symptom
25
objective abnormality that you as the examiner could detect on physical examination or lab reports
sign
26
Techniques of physical assessment
1. INSPECTION
2. PALPATION
3. PERCUSSION
4. AUSCULTATION
27
5 Percussion notes
```
RESONANT
HYPERRESONNANT
TYMPANY
DULL
FLAT
```
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TYPE OF SOUND HEARD WHEN PERCUSSING:
* normal lung tissue
RESONANT
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TYPE OF SOUND HEARD WHEN PERCUSSING:
* normal over child's lung
* abnormal in the adult, over lungs with increased amount of air (emphysema)
HYPERESONNANT
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TYPE OF SOUND HEARD WHEN PERCUSSING: over air-filled viscus, such as stomach or intestines
TYMPANY
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TYPE OF SOUND HEARD WHEN PERCUSSING: relatively dense organ, as liver and spleen
DULL
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TYPE OF SOUND HEARD WHEN PERCUSSING: when no air is present, over thigh muscles, bone or tumour
FLAT
33
TRUE OR FALSE?
STETHOSCOPE MAGNIFIES SOUND
FALSE -
| * does not magnify sound but does block out extraneous room sounds
34
PART OF STETHOSCOPE TO USE TO AUSCULTATE: for high-pitched sounds, such as breath, bowel, and normal heart sounds.
DIAPHRAGM
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PART OF STETHOSCOPE TO USE TO AUSCULTATE: for soft, low-pitched sounds, such as extra heart sounds or murmurs.
BELL
36
DEVELOPMENTAL CARE FOR WHICH AGE GROUP:
* timing - 1 to 2 hours after feeding when baby is not too drowsy or hungry
* environment - warm
* considerations - infant will not object to being nude or being touched, but make sure hands & equipment are warm
* voice - use soft, crooning voice
* eye contract - lock eyes from time to time
* facial expression - baby prefers a smiling face to frowning face
* movements - smooth and deliberate, not jerky
* distractions - use pacifier during invasive steps or distract with brightly coloured toys
INFANT - developmental stage: establishing trust
37
WHAT IS THE INFANTS DEVELOPMENTAL STAGE KNOWN AS?
ESTABLISHING TRUST
38
DEVELOPMENTAL CARE FOR WHICH AGE GROUP:
* need to explore is in conflict with dependency on parent
* often results in frustration
* may be difficult to examine
* may be fearful of invasive procedures and dislike being restrained
TODDLER
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WHAT IS THE TODDLERS DEVELOPMENTAL STAGE KNOWN AS?
developing autonomy
40
WHAT IS THE General Survey
* overall impression of the patient
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WHEN DOES THE GENERAL SURVEY BEGIN?
* begins when you first encounter him or her
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4 AREAS COVERED IN GENERAL SURVEY
* 1. physical appearance
* 2. body structure
* 3. mobility
* 4. behavior
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2 THINGS TO NOTE WHEN PERFORMING GENERAL SURVEY OF INFANTS AND CHILDREN
1. PARENTAL BONDING
| 2. PHYSICAL GROWTH
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3 THINGS TO NOTE WHEN PERFORMING GENERAL SURVEY OF OLDER ADULTS
1. PHYSICAL APPEARANCE
2. POSTURE
3. GAIT
45
TRUE OR FALSE?
in terms of blood pressure, there is normally a gradual decline that occurs throughout childhood and into the adult years
FALSE. gradual rise is normal
46
CAUSE OF TRIPOD POSITIONING
BREATHING DIFFICULTIES OR LUNG DISEASE
47
PROPER WAY TO TAKE RADIAL PULSE:
* palpate the radial pulse at the flexor aspect of the wrist laterally along the radial bone
* push until you feel the strongest pulsation
* if rhythm is regular, count the number of beats in 30 seconds and multiply by 2
48
4 THINGS TO NOTE IN RADIAL PULSE
1. RATE
2. RHYTHM
3. FORCE
4. ELASTICITY
49
THINGS TO REMEMBER WHEN TAKING Blood Pressure
- ARM AT HEART LEVEL
- FEET ON FLOOR
- PALPATE RADIAL ARTERY AND NOTE WHEN IT DISAPPEARS WHILE CUFF IS INFLATING
- ADD 20-30 MM HG
- DEFLATE CUFF SLOWLY AND GRADUALLY
50
WHAT ARE THESE SYMPTOMS CHARACTERISTIC OF:
* irregularity commonly found in children and young adults
* heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing down to normal with expiration
Sinus arrhythmia
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the maximum pressure felt on the artery during left ventricular contraction (or systole).
systolic blood pressure
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is the elastic recoil (or resting) pressure the blood exerts constantly between contractions.
diastolic blood pressure
53
is the difference between the systolic and diastolic pressures and reflects the stroke volume.
Pulse pressure
54
Reason for checking for auscultatory gap before doing BP
* this will avoid missing the auscultatory gap - a period when Korotkoff's sounds disappear during auscultation
55
Assessment findings indicating acute pain
* guarding
* grimacing
* vocalizations such as moaning
* agitation
* restlessness
* stillness
* diaphoresis
* change in vital signs
56
pain-indicating behaviours
* rocking
* negative vocalization
* frowning
* grimacing
* noisy breathing
* irritability
* agitation
* rubbing a panful area
* bracing
57
__________ PAIN:
* pain originates from the larger interior organs (kidney, stomach, intestine, gallbladder, pancreas)
* constant or intermidant
visceral
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__________ PAIN:
| superficial pain derived from skin surface or subcutaneous tissues (joints, tendons, muscles or bone)
somatic
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__________ PAIN:
* pain initiated or caused by a primary lesion or dysfunction of the nervous system
* caused by injury to either peripheral or central nervous system
neuropathic
60
________ PAIN: persistant pain present for 6 months or longer
chronic
61
_________ PAIN:
* short-term or self-limiting
* often follows a trajectory
* dissipates after injury heals
acute
62
possible findings in the Mental Status Assessment of Older Adults
* slower response time
* decreased recent memory
* age-related changes in sensory perception can affect mental status
* confusion
* cognitive impairment
63
When do you need to perform a complete mental status assessment
abnormality in the following:
- behavioural changes
- brain lesions (trauma, tumour, stroke)
- aphasia
- symptoms of psychiatric mental illness
64
DEFINITION: Drifts off to sleep when not stimulated
lethargic
65
DEFINITION: slow response, sleeping most of the time, difficult to arouse.
obtunded
66
DEFINITION: Responds only to persistent or vigorous shake or pain.
stuporous
67
WHAT KIND OF ASSESSMENT IS CHARACTERIZED BY THE FOLLOWING:
- simplified scored assessment of cognitive functions
- includes a brief assessment of memory, orientation to time and place, naming, reading, copying or visual-spatial orientation, writing, and the ability to follow a three-stage command.
- detect dementia and delirium.
MINI-MENTAL
68
SKIN OF INFANT OR OLDER ADULT?
1. thin, smooth, elastic and relatively permeable
2. greater fluid loss
3. temperature regulation is ineffective
4. sebum is present in first few weeks, producing milia and cradle cap
5. subcutaneous layer is inefficient
6. pigment system is inefficient at birth
INFANT
69
SKIN OF INFANT OR OLDER ADULT?
1. COLOUR OR PIGMENTATION - senile lentigines (liver spots)
2. MOISTURE: dry skin is common
3. TEXTURE: acrochordons (skin tags)
4. THICKNESS: skin becomes thinner as subcutaneous fat diminishes
5. MOBILITY & TURGOR: turgor is decreased (less elasticity), skin recedes slowly and "tents"
70
Skin provides information about – what?
temperature
71
Clubbing of nails is typical in what condition?
chronic obstructive pulmonary disease
72
What are small, flat, brown macules known as?
liver spots or senile lentigines
73
DEFINITION: something you can feel caused by superficial thickening in the epidermis
papule
74
DEFINITION: soley a colour change, flat and circumscribed, of less that 1 cm. eg. freckle
macule
75
DEFINITION: solid, elevated, hard or soft, larger than 1 cm. deeper than papule
nodule
76
DEFINITION: single-chambered, superficial in the epidermis, thin-walled so ruptures easily eg. blister
bulla
77
DEFINITION: normal skin feels smooth and firm, with an even surface
Texture
78
DEFINITION: an abnormal accumulation of fluid in the interstitial spaces
Edema
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DEFINITION: skin's ease of rising
mobility
80
DEFINITION: skin's ability to return to place when promptly released - reflects the elasticity of the skin
turgor
81
DEFINITION: Of, characterized by, or containing vessels that carry or circulate fluids, such as blood, lymph, or sap, through the body of an animal or plant.
vascularity
82
DEFINITION: the time it takes for a nail bed to return to its usual colour after the blood flow has been momentarily occluded. An indicator of peripheral circulation
Capillary refill
83
DEFINITION: male pattern baldness
Alopecia
84
DEFINITION: the bluish discolouration of the skin and mucous membranes caused by an excess of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule
Cyanosis
85
DEFINITION: a redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries; sunburn is an example
Erythema
86
DEFINITION: the yellow discolouration of the skin, mucous membranes, and sclera, caused by greater than normal amounts of bilirubin in the blood
jaundice
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DEFINITION: any localized, abnormal structural change in the skin
lesion
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DEFINITION: an unnatural paleness or absence of colour in the skin
pallor
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DEFINITION: itching or the uncomfortable sensation leading to the urge to scratch
Pruritus
90
Mole Assessment Mnemonic - ABCDE
* ASYMMETRY - symmetrical circle shape
* BORDER - no border present
* COLOUR - light brown
* DIAMETER - not greater than 6 mm (approx. 3 mm diameter)
* ELEVATION & ENLARGEMENT - .5 - 1 mm high
91
Salivary glands that are accessible to examination on the face
parotid
| submandibular
92
WHERE ARE THE parotid SALIVARY GLANDS LOCATED?
glands in the cheeks over the mandible, anterior to and below the ear
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WHERE ARE THE submandibular SALIVARY GLANDS LOCATED?
glands beneath the mandible, lie in the angle of the jaw
94
Thyroid gland and tests
* watch person drink glass of water - thyroid moves up with a swallow
* if the thyroid is enlarged, auscultate it for bruits - presence of bruit is an indication of hyperthyroidism
95
Four areas in body where lymph nodes area accessible
1. head and neck
2. arms
3. axillae
4. inguinal regions
96
DEFINITION: an abnormal blowing or swishing sound or murmur heard while auscultating a carotid artery, the aorta, an organ, or a gland, such as the liver or thyroid, and resulting from blood flowing through a narrow or partially occluded artery
BRUITS
97
Signs of dehydration in infant
- More than six to eight hours without a wet diaper
- Urine that looks darker in his diaper and smells stronger than usual
- Lethargy (low energy)
- A dry, parched mouth and lips
- No tears while crying
98
Signs of serious dehydration in infants:
- Sunken eyes
- Hands and feet that feel cold and look splotchy
- Excessive sleepiness or fussiness
- Sunken fontanels (the soft spots on your baby's head)
99
DEFINITION: glaucoma resulting in gradual loss of peripheral vision
increased intraocular pressure
100
DEFINITION: adaptation of the eye for near vision accomplished by increasing curvature of lens through movement of ciliary muscles
accommodation
101
DEFINITION: different sized pupils
anisocoria
102
Meaning of 20/30 from Snellen eye chart
meaning they can read letters at a distance of 20 feet that most people can read at a distance of 30 feet
103
Findings of red glow with ophthalmoscope
red reflex - reflection of ophthalmoscope light off retina, begin about 25 cm away from person
104
Description of tympanic membrane
translucent membrane with pearly grey colour and prominent cone of light in the anteroinferior quadrant
105
Findings in ear drainage from basal skull fracture
cerebral spinal fluid (CSF)
106
Voice Test
* done by placing one finger on the tragus and rapidly pushing it in and out of the auditory meatus
* shield your lips so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using "good" ear
* with your head 30 to 60 cm from person's ear, exhale and whisper slowly some 2-syllable words like "tuesday, armchair, baseball"
107
Response in infant/child when assessing hearing
NEWBORN - startle (moro) reflex, acoustic blink reflex
3-4 MONTHS - acoustic blink reflex, infant stops movement and appears to "listen", halts sucking, quiets if crying, cries if quiet
6-8 MONTHS - infant turns head to localize sound, responds to own name
PRESCHOOL & SCHOOL-AGE - child must be screened with audiometry
* young children may be unaware of hearing loss because child does not known how one "ought" to hear.
108
Weber Test OR Rinne test?
| person should hear tone by bone conduction (BC) through the skull and it should sound equally loud in both ears
WEBER
109
Weber Test OR Rinne test?
| normal response in a positive test or "AC>BC"
RINNE
110
Weber Test OR Rinne test?
place vibrating tuning fork in the midline of person's skull and ask whether tone sounds the same in both ears or better in one
WEBER
111
Weber Test OR Rinne test?
* place the stem of the vibrating tuning fork on the person's mastoid process and ask him to signal when the sound goes away
* quickly invert the fork so the vibrating end is near the ear canal; the person should still hear a sound
RINNE
112
NAME THE ORGAN:
* Behind the anterior tonsillar pillar are the tonsils
* mass of lymphoid tissue
* same colour as the surrounding mucous membrane
* Look more granular
* Surface shows deep crypts (indentations)
TONSILS
113
WHAT IS Difficulty swallowing KNOWN AS?
Dysphagia
114
Where most breast cancers are found
upper outer quadrant of breast
115
How to interview adolescent about breast development
Assess each girl's perception of her own development, provide teaching and reassurance as indicated.
"Have you noticed your breasts changing?"
"How long has this been happening?"
116
6 DIAGNOSTIC CATEGORIES OF Benign breast disease
1. Swelling and tenderness
2. Mastalgia (severe pain, both cyclical and non cyclical)
3. Nodularity ((significant lumpiness, both cyclical and non-cyclical)
4. Dominant lumps (including cysts and fibroadenomas)
5. Nipple discharge (including intraductal papilloma and duct ectasia)
6. Infections and inflammations
117
Changes in breasts and nipple that could indicate cancer
* firm/hard irregular axillary nodes
* Skin dimpling
* Nipple Retraction
* Nipple elevation
* Nipple discharge
118
How to examine breasts
- Place client in supine position with her arm raised over her head
119
Best time to perform breast self examination (BSE)
Right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested.
120
What is the Posterior Thoracic Landmark?
Vertebra prominens
121
Where are the vertebra prominens located?
the upper one is C7 and lower one is T1
122
Normal assessment findings of adult lungs
Resonance is the low pitched, clear, hollow sound that predominates in healthy lung tissue in the adult.
123
What is Tactile fremitus
* Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall, where you feel them as vibrations.
124
Possible percussion notes on the lungs and their indications
resonant - normal
dull - abnormal lung density; atelectasis or tumour
stoney dull - pleural effusion
125
Causes of decreased breath sounds
- obstructed bronchial tree by secretions, mucus plug, or a foreign body
- emphysema
- pleural thickening, or air in the pleural space
126
Hyperresonant percussion notes indicates what?
emphysema or pneumothorax
127
Bronchophony, egophony and whispered pectoriloquy?
Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said.
Bronchophony
128
Bronchophony, egophony and whispered pectoriloquy?
Normally, you should hear "eeeeeeeee" through your stethoscope while the person phonates "eeeeee"
egophony
129
Bronchophony, egophony and whispered pectoriloquy?
The normal response is faint, muffled, and almost inaudible while the person whispers.
whispered pectoriloquy
130
Normal breath sounds and their locations
Bronchial: Trachea and Larynx
Bronchovesicular: Over major bronchi
Vesicular: Over peripheral lung fields, where air flows through smaller bronchioles and alveoli
131
Abnormal breath sounds:
Discontinuous, high pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing.
Crackles (fine)
132
Abnormal breath sounds:
Loud, low pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration.
Crackles (coarse)
133
Abnormal breath sounds:
Sounds like fine crackles but do not last and are not pathological
Atelectatic crackles
134
Abnormal breath sounds:
superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together
Pleural Friction Rub
135
Abnormal breath sounds:
musical squeak predominate in expiration but may occur in both expiration and inspiration
Wheeze
136
Abnormal breath sounds:
High pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest wall.
Stridor
137
Correct use of stethoscope to auscultate breath sounds
* Hold the flat diaphragm end piece of the stethoscope firmly on the person's chest wall. Listen to at least one full respiration in each location.
138
Part of brain that helps coordinate movement, maintains equilibrium, and helps maintain posture
cerebellum
139
DEFINITION: Ever feel lightheaded, a swimming sensation, like feeling faint?
VERTIGO
140
DEFINITION: fainting, sudden loss of strength/consciousness
syncope
141
Infant reflexes
- rooting
- moro/startle
- sucking
- palmar
- babinski
142
In this neurological assessment, the patient is stood up and asked to close his eyes. A loss of balance is interpreted as a positive sign
Romberg test
143
when someone can't identify something in their hand with their eyes closed
Astereognosis
144
documentation of normal plantar reflexes
plantar flexion of toes and inversion of flexion of forefoot.
145
ability to read a number on a trace of skin
graphesthesia
146
ability to distinguish separation between 2 points on skin
two point discrimination
147
WHAT IS THE Cremasteric reflex
TESTICLE REFLEX
148
is a quantitative tool that is useful in testing consciousness in older adults who may be experiencing confusion. It gives a numerical value to the person’s response in eye-opening, best verbal response, and best motor response.
Glasgow coma scale
149
technique to relax muscles and enhance response
reinforcement
150
What is the Denver II used to screen for
Gross motor skills and coordination in school aged child
151
Ominous sign which indicates brain stem injury
unilateral, dilated and nonreactive pupil
152
The Cushing reflex showing signs sudden widening pulse pressure & decreased pulse is an indication of what
increased intracranial pressure
