Unit 2 Flashcards
(167 cards)
1
Q
What is the criteria for SIRS?
A
Temp: >38 or <36
Heart rate: >90
Resp rate: >20
Increased WBC
2
Q
What are the 2 types of peritoneum?
A
Visercal and Parietal
3
Q
What organs are considered solid? (6)
A
Adrenal glands (located on top of kidneys)
Liver
Ovaries
Pancreas
Spleen
Uterus
4
Q
What organs are considered hollow? (4)
A
Bladder
Large intestine (Colon)
Gall bladder
Small intestine
5
Q
What is the definition of hollow organs?
A
Organs that are smushed when there is nothing in them, but can fill and expand while in use
6
Q
Where is and what does costovertebral angle pain indicate?
A
Between 12 rib and spine.
Pylonephritis
7
Q
What is considered an upper UTI?
A
Infection of ureters and above
8
Q
What is considered a lower UTI?
A
Infection of bladder or below
9
Q
In which order do we assess the abdomen?
A
Inspect
Auscultate
Percuss
Light Palpation
Deep palpation
10
Q
What are the 4 types of bowel sounds?
A
Hyperactive= >30 bowel sounds/minute
Normoactive= 5-30 bowel sounds/minute
Hypoactive= <5 bowel sounds a minute
Absent= No bowel sounds- must listen for 5 minutes
11
Q
Organs in LUQ (6)
A
Left kidney
Left liver lobe
Pancreas (Body)
Spleen
Stomach
Colon (descending and other portion of transverse)
12
Q
Organs in RUQ (5)
A
Colon
Duodenum
Gall bladder
Liver
Pancreas
13
Q
What labs are drawn to check function of pancreas?
A
Amylase and lipase
14
Q
A
15
Q
Organs LLQ (5)
A
Left ovary
Left spermatic cord
Left ureter
Descending colon
Sigmoid colon
16
Q
Organs RLQ (5)
A
Appendix
Cecum
Right ovary/tube
Right spermatic cord
Right ureter
17
Q
What is considered normal number of bowel movements a week?
A
At least 3 per week
18
Q
An ileostomy is located where? What type of stool should be observed?
A
Ascending colon (right side)
Liquidy stool
19
Q
A colostomy is located where? What type of stool should be observed?
A
Descending colon
Formed stool
20
Q
Normal hemoglobin in M/F and point in which to give blood
A
Female= 12-16
Male= 14-18
Normal patient: hemoglobin below 7
Heart patient (such as CHF): Hemoglobin below 8
21
Q
How is visceral pain described?
A
Dull and general
22
Q
How is Parietal pain described?
A
Sharp and localized
23
Q
What medications may be given for nausea?
A
Ondansetron (Zofran)
Metoclopramide (Reglan)
Meclizine (Compazine)
Phenergan
24
Q
What do you need to check in patient prior to giving zofran?
A
Pts QT interval
25
What is a well known side-effect of phenergan?
May make pt loopy
26
Upper GI Bleed (stool appearance)
Coffee ground stool, tarry (melena)
27
Occult blood
Hidden blood in stool
28
Gray stool is associated with...
Hepatitis due to bilirubin
29
Which type of stroke is known to cause dysphagia?
Ischemic stroke
30
Why do we palpate and percuss last when doing an abdominal exam?
May result in increased peristalsis
31
What is striae associated with?
Excess weight gain
Ascites
Cushing's Syndrome
Pregnancy
32
Normoactive bowel sounds
Heard 5-30 times per min
33
Hyperperistalsis (stomach rumbling)- is also known as....
Borborygmus
34
Arteries used to assess for bruit in abdomen
Aortic
Renal (Left and right)
Iliac (Left and right)
Femoral (Left and right)
35
T/F
We may listen for bowel sounds to confirm accuracy of NG tube placement.
FALSE
36
Best way to confirm NG placement
x-ray
37
What may be associated with rigidity (stiffness) upon light palpation?
Peritonitis
38
Depth for deep palpation
5-8 cm
39
Bimanual technique of palpation should be used for....
Obese patients
40
Mild tenderness upon palpation is expected where?
Sigmoid colon- top of stomach between 2 rib cages
41
If a pt is diagnosed with splenomegaly, what is important to teach?
No contact sports due to risk of spleen rupture (which would cause immunosuppression for life)
42
What specific disease state may be seen with splenomegaly?
HIV
43
What is the duckbill position?
Way to palpate kidney's
44
What is one of the first signs of gout?
Greater toe pain
45
3 types of joints
Fibrous- sutures in skin
Cartilaginous- vertebrae
Synovial-knee
46
What joint is avascular?
Synovial
47
Ligaments
Connect bone to bone
48
Tendons
Muscle to bone
49
Abduction
Away from body
50
Adduction
Move towards body
51
Pronation
forearm turn with palm down
52
Supination
forearm turn with palm up
53
Flexsion
limb bending at a joint
54
Extension
straightening of limb at a joint
55
T/F
You cannot check vitals on a patients specific side if they've had a removal of lymph nodes
True
56
T/F
Blood pressure rises throughout the day- lowest in the am.
True
57
Tail of Spence
Superior lateral corner of breast tissue that projects up and laterally to midaxillary
58
Purpose of Montegomery's Glands
Secrete protective lipid material during lactation (COLOSTRUM)
59
The breast is composed of what 3 types of tissues?
Glandular Tissue
Fibrous Tissue
Adipose Tissue
60
How may sections is the breast divided into?
4
61
The regional lymphatic system works parallel with what other system?
Venous System
62
3 types of preventions
-Primary: Preventative (Seatbelt/Vaccines)
-Secondary: Screening (Mamogram)
-Tertiary: Damage is done- just trying not to make it worse
63
Mastalgia
Pain or tenderness of the breasts
64
If a lump is noticed in the body what are some things to ask the patient?
How long has it been there?
Has there been any change with it (size and/or pain/absence of pain)
65
Galactorrhea
Nipple Discharge
66
4 drug classes associated with galactorrhea and 2 examples of each
- Calcium channel blockers (Amlodipine and Nifedipine)
- Diuretics (Furosemide and HCTZ)
- Oral contraceptives (Junel 1/20 and Yaz)
- Steriods: Dexamethasone and Prednisone
67
What gene may be associated with breast cancer?
BRCA gene
68
GO BACK TO SLIDE 12 (BREAST)
69
Gynecomastia
Male enlargement of breast tissue
70
What disease states may cause gynecomastia?
Cushing Syndrome
Liver Cirrhosis
Hyperthryoidism
Alcholism
70
What drug may cause gynecomastia?
Sprinolactone
71
What is a significant warning sign of breast cancer in men?
Nipple discharge
72
T/F
With breast cancer in men, it is characterized as a soft, tender, and regular
False
Breast cancer in men is characterized as a fixed area, hard, nontender, and irregular
73
What ribs are floating and may be a concern for injury?
Ribs 11 and 12
74
Suprasternal notch
U-shaped depression just above the sternum between clavicles (top of breast bone)
75
Sternum
Also known as the breast bone.
Made up of Manbrium (top), body, and Xiphoid process (bottom)
76
Angle of Louis refers to the...
Sternal angle
77
Costal Angle
Angle between bottom of 2 ribs starting at xiphoid process
78
Pleaural fusion in coastal angle is a sign of...
Atelectosis (lung collapse)
79
Where is the vertebra prominens located?
C7
80
If there is damage to the vertebra prominens (C7), what could this result in for the patient?
Paraplegia or vent for the rest of life
81
Spinous Processes
Count down these knobs on vertebrae, which stack together to form spinal column
82
What is included in the mediastinum? (4)
- Esophagus
- Great vessels (aortic, vena vessels)
- Heart
- Trachea
83
Surfactant
Helps with lubrication of pleural cavity
84
What disease state is due to lack of surfactant?
Cystic Fibrosis
85
Hypercapnia and normal levels
Increased levels of CO2 in blood
Normal: 35-45
86
Hypoxemia and normal levels
Decreased oxygen in blood levels or lack of perfusion
Normal O2- 94-100%
87
Altered mental status until proven otherwise...
Hypoxia
88
How do you assess hypoxia?
ABG and SPO2
89
2nd most diagnoised cancer in the USA?
Lung cancer
90
Rust color sputum is associated with what disease states?
Pneumonia or TB
91
Yellow/Green Sputum
Bacterial infection
92
White/Clear Sputum
Viral infection (meningitis), bronchitis, or colds
93
Pink Sputum
Pulmonary edema or pulmonary hypertension
94
Why may a 67 y/o female be taking sildenafil (viagra)?
Pulmonary hypertension
95
Barrel Chest
Associated with COPD
Diameter is 1/1 versus the normal 2/1
96
What would increased fremitus indicate?
Consolidation of the lung (more fluid in lungs)
Pneumonia
97
What would decreased fremitus indicate?
Possible obstruction of the lungs
Pleural effusion/hemothorax, pneumonthorax
98
Resonance
- What does it sound like?
- With what part of the assessment does it go with?
A clear, low-pitched, hollow sound
Considered "normal" sound with percussion
99
Hyperresonance
So-called booming sound with substantial amount of air present
Seen w/ pneumothorax or emphysema
100
Dull sound finding
So-called muffled, soft thud sound
101
When auscultating the chest how many places do we need to listen to?
At least 9
102
Where would you hear bronchial sounds?
Nech and trachea
103
Where would you hear vesicular sounds?
Over lung space
104
Where would you hear bronchovesicular sounds?
Inside of chest- right next to sternum on left and right side
105
Fine crackles (rales) and what disease state associated w/ it?
High pitched, short, discontinuous popping sound
So-called late inspiratory crackles associated with pneumonia and heart failure
106
Crackles
Coarse, low-pitched, bubbling and gurgling
Associated with pulmonary edema and pulmonary fibrosis (SCAR TISSUE DEVELOPMENT)
107
High-pitched (sibilant) Wheeze and disease state is associated w/ it?
Squeaking sounds, usually heard in expiration but can occur with inspiration
Associated with acute asthma obstruction or chronic emphysema
108
Low-pitched (sonorous rhonchi) Wheeze
So-called moaning sound, usually heard in expiration but can occur with inspiration
Associated with bronchitis
109
Stridor
High-pitched inspiratory, so-called crowing sound
Sibilant wheeze associated with Croup, acute epiglottitis
CAN BE LIFE THREATENING
110
of vertbrae in cervical
7
111
of vertebraes in thoracic
12
112
of vertebraes in lumbar
5
113
of vertebraes in sacral
5
114
of vertebraes in coccygeal
3-4
115
What is a sign of torn rotator cuff?
Limted ROM- can only laterally raise arm to shoulder height
116
If you're draining synovial fluid in a patients joint, what should you always ask the provider?
If they want it send to lab
117
How is strength documented?
5/5- Normal strength
4/5
3/5- Move against gravity w/o help
2/5- Dead weight and nurse does lifting
1/5- Paralyzed
118
Name a ball and socket joint
hip
119
We would frog leg a patient to assess what?
Internal and external rotation of hip
120
Name a hinge joint
Knee
121
What would we use to assess foot drop?
Plantar and dorsiflexsion
122
What is the largest joint in the body?
Knee
123
Holmans Sign
PAIN IN CALF WHILE PLANTAR FLEXSION AND DORSIFLEXSION COULD BE A SIGN OF DVT
124
Activities of Daily Living (ADL’s)- Definition
Daily tasks in which the patient should perform independently, with assistance or assistive device or with requirement of total patient care
125
Examples of ADL's
Bathing
Communication
Dressing
Eating
Grooming
Mobility
Toileting
126
What is the systemic approach during a physical examination?
head to toe, proximal to distal, and from midline outward
127
Passive ROM
Pt needs assitance
128
Active ROM
Pt can perform on their own
129
Order of examination for muscloskeletal
Inspect, palpate, ROM
130
Frontal Lobe
Concerned with personality, behavior, emotions, and intellectual function
131
Parietal Lobe
Postcentral gyrus is primary center for sensation
132
Occipital Lobe
Primary visual receptor centor
133
Temporal Lobe
Behind ear, primary auditory reception center, taste and smell
134
Wernickes Area (Where is it located and what is it for?)
Located: Temporal Lobe
Purpose: Speech comprehension
135
Broca's Area (what is it?)
Processes motor aspect of speaking (trachea, larnyx, etc)- ability to talk and annunciate
136
The main relay station where sensory pathways of spinal cord, cerebellum, and brainstem form _________.
Synapses
137
Cerebellum
Concerned w/ motor coordination and muscle tone of voluntary movements
138
Brainstem
Controls on going functions (breathing, heart rate, lung ventilation)
Contains pons, midbrain, and medulla
139
Name the 3 types of deep reflexes
Deep tendon/stretch
Superficial (cutaneous)
Visceral (organic)
140
Example of deep tendon/stretch reflex
Knee jerk
141
Example of superficial (cutaneous) reflex
Baby grabbing finger
142
Example of visceral (organic) reflex
Pupillary response
(We as humans- cannot control visceral reflex)
143
Name 3 types of seizures
Subclinical (AKA simple/partial)- type of seizure
Tonic Clonic seizure- Effects whole brain, known as the "Hollywood" seizure
Status Epilepticus- Medical emergency, repeatitive, continuous, and life threatening. Respiratory depression and respiratory arrest may accompany
144
After a seizure, how may a patient present?
Dazed, confused, lethargic, glossiness over face, drooped face or features, slurring words
145
Aura
Feeling a patient may have when they experience that a seizure may be coming on
146
What bowel pattern is expected after a patient has any surgery, but specifically abdominal surgery?
Hypoactive
147
What pathology may present with hyperactive bowel sounds?
Partial GI Obstruction
148
Name 2 types of strokes
Ischemic- due to lack of oxygen to the brain
Hemmoraghic- Rupture and break of vessel
149
What is important to ask when assessing for a seizure and why?
"When was the patient last themselves?"
To understand if we're able to help. Typically if its been 4-6 hours post-seizure, damage is done
150
In which order do complete a neurological exam?
Mental status
Cranial nerves
Motor System
Sensory System
Reflexes
151
What type of prevention is screening neurologic exam?
Secondary
152
Bone marrow production of RBC's, WBCs, and platelets is known as...
Hematopoiesis
153
Dysphagia
Has a g-Difficulty swallowing
154
Dysphasia
Difficulty speaking
155
Spinal nerve # per region
-Cervical 8- Citrus at 8
-Thoracic 12- Tea at 12
-Lumbar and sacral 5- Lemonade and salmon at 5
-Coccygeal - 1
156
T1 dermatome injury
Axilla
157
T4 dermatome injury
Nipple
158
T10 dermatome injury
Unbilicus
159
L1 dermatone injury
Groin
160
L4 dermatone injury
Knee
161
Cranial nerve 1 and test
Olfactory - Sniff test
162
Cranial nerve II and test
Optic - visual acuity and snellen chart
163
Cranial nerve III, IV, VI test
Cardinal positions of gaze
164
Cranial nerve V and test
Facial-
Motor= clench teeth w/ nurse feeling
Sensory= Sensation w/ cotton ball on forehead, cheeks, and chin
166
Where can the angle of louis be palpated?
Second rib and slide down to the second intercostal space
167
If the vertebra prominens is damaged- what can be a result for a patient?
Vent or paraplegia for life
