1102 Test 2 Review

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1102 Test 2 Review
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1102 Test 2 Review
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  1. Core temperature
    temperature of deep tissues
  2. What part of the body regulates tempurature
    The Hypothalamous
  3. What does the hypothalamous do to regulate tempurature?
    attempts to maintain a comfortable temperature, or set point it lowers temperatures through sweat, and vasodilatation, and raises temperatures through, Shivering, and Vasoconstriction.
  4. Heat is produced as a byproduct of what
     metabolism
  5. Nonshivering thermogenisis
    OccursIn neonates, because they can’t shiver,a limited amount of brown adipose tissue present at birth can be metabolized tocreate heat
  6. Shivering
    involuntary response to temperature differences in the body, Shivering can increase heat production 4 – 5 times greater than normal
  7. Radiation
    thetransfer of heat between objects without physical contact up to 85% of thehuman’s biyy surface radiates heat to the environment
  8. Conduction
    transfer of heat from one object to another, when warm skin touches a cooler object, heat transfers from the skin, until the temps are similar.
  9. Convection
    transferheat away from the body by air movement
  10. Evaporation:
    : transfer of heat energy when liquid is changed to a gas – body continuously looses heat by evaporation, about 600 – 900 mL of water a day evaporates form skin and the lungs
  11. Diaphoresis
    visually evident perspiration
  12. 10 pulse points, and where they are
  13. Location of the temporal pulse
    over the temporal bone of the head, above and lateral to eye
  14. Location of the Carotid pulse
    along medial edge of the sternoclydomastoid muscle in the neck
  15. location of the Apical pulse
    fifth intercostal space, at left midclavicular line
  16. Location of the Bracial pulse
    Groove between biceps and triceps muscle at antecubital space
  17. Radial
    radial or thumb side of forearm at the wrist
  18. Ulnar
    Ulnar side of forearm at wrist
  19. Femoral
    Below the inguinal ligament, midway between the sypphasis pubis, and anterios superior iliac spine
  20. Popliteal pulse location
    Behind knee in popliteal fossa
  21. Posterior tibial pulse site
    Behind the knee in the popliteal fossa
  22. Dorsalis pedis pulse site
    along the top of foot, between extension tendoons of great and first toes
  23. four means of heat loss and an examole of each
    • Radiation - loosing body heat into cold air
    • conduction - ice pack, or bathing with tepid water
    • convection  - cooling off with a fan
    • evaporation - sweating
  24. Hyperthermia
    An elevated body tempurature R/T bodys inability to premote heat loss or reduce heat prodution
  25. Hypothermia
    heat loss during prolonged exposure to cold over whelms the body's ability to produce heat.
  26. S/S of Hyperthermia
    Giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence
  27. What is indicated by the following S/S
    Giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence
    Hyperthermia
  28. S/S of Hypothermia
    Uncontrolled shivering, loss of memory, poor judgement, slowed heart rate, and blood pressure decrease
  29. What is indicated by the following S/S?
    Uncontrolled shivering, loss of memory, poor judgement, slowed heart rate, and blood pressure decrease
    Hypothermia
  30. Dysrythmia
    abnormal heart rythm
  31. Brandycardia
    less than 60 BPM for adults
  32. Tachycardia
    more than 100 BPM in an adult
  33. Auscultation of lungs
    • Place diaphragm firmly on  skin, over posterior chest wall between ribs. the patient folds arms infront of the chest, and keeps the head bent forward while taking slow, deep breaths with mouth slightly open. use a systematic pattern comparing the sounds on one side of the body with the sounds on the same region of the other side
    • a.       Listen to an entire inspiration and expiration at each position of the stethoscope. (There are 6 positions to listen to...both on the chest and the back...so you can hear all the lobes of the lungs)
  34. What is another assesment that can be done when chectking an arythmia?
    asses the apical and radial pulses while two examiners are present. the radial pules is slower than apical pulse, it is called a DEFICIT
  35. Auscculation of the abdomin
    • a.       Place the warmed diaphragm of the stethoscope lightly over each of the Four quadrants. It takes 5 to 20 seconds to hear a bowel sound. However, If no sounds are heard, wait 5 full minutes before determining if bowel sounds are absent.
    • a.       Auscultate all four quadrants to be sure you do not miss any sounds.
    • a.       Absent sounds indicate a lack of peristalsis, possibly due to a bowel obstruction, paralytic ileus, or peritonitis. Hyperactive sounds are loud, "growling" sounds which indicate increased GI motility. Inflammation of the bowel, anxiety, bleeding, excess ingestion of laxatives, and reaction of the intestines to certain foods cause increased motility.
  36. Asculation for heart sounds
    •   There are 5 sites for assessment of cardiac function (All People Enjoy Time Magazine)
    • Aortic                 
    • Pulmonic                            
    • Tricuspid           
    • Mitral
  37. Baseline assesment by parts,
    Part 1 - Pre-assesment
    • 1: Wash Hands
    • 2: Gather equipment
    •     a: stethoscope, BP cuff, penlight, watch, tongue blade, gloves, reflex hammer
  38. Baseline assesment by parts,
    part 2: Introduction and general survey
    • i.      introduce self                                                 
    • ii.      identify pt                                                         
    • iii.      explain purpose and procedure  
    • iv.      put pt. at ease                                                           v.      answer questions
    • vi.      general survey of pt and pt mental status (patient orientation to person, place and time)
  39. Baseline assesment parts:
    Part 3: Vital signs
    temp., radial pulse, respirations, BP
  40. Baseline assesment parts,
    Part 4: Skin
    • i.      inspect for lesions or abnormalities               
    • ii.      palpate for temp. and swelling  
    • iii.      test for turgor (hand/arm of younger person. Chest in older person)
  41. baseline assesment parts:
    Part 5: Head and face
    • i.      inspect head and scalp for lesions, abnormalities, dandruff, lice  
    • ii.      temporal artery                                       
    • iii.      palpate sinuses (tenderness)
  42. Base line assesment parts:
    Part 6: Eyes
    • i.      external eyes                                                            ii.      test EOM (extra ocular movement)    
    • iii.      pupils PERRLA
  43. Base line assesment parts:
    Part 7: ears
    • i.      external ear                               
    • ii.      test hearing (tuning fork/snap )                               
    • iii.      move auricle and push on tragus
  44. Base line assesment parts:
    Part 8: mouth and throat
     i.      Using  penlight look at: buccal mucosa, teeth, gums, tongue, palate, tonsils
  45. Base line assesment parts:Part 9:
    mouth and throat
    i.      Using  penlight look at: buccal mucosa, teeth, gums, tongue, palate, tonsils
  46. Base line assesment parts:
    Part 10: Nose
    • i.      inspect nose (penlight)       
    • ii.      Test for patency of nares
  47. Base line assesment parts:
    Part 11: Neck
    •  i.      inspect     
    • ii.      palpate lymph nodes                                    
    • iii.      Carotid pulse                                                    
    • iv.      Test ROM for neck and check for strength of neck
  48. Base line assesment parts:
    Part 12: Chest
    • i.      inspect/palpate posterior chest                           ii.      spinous process                                                  iii.      Chest rise and tactile                                              iv.      Chest excursion                                                      v.      CVA tenderness (costal vertebral angle)                 vi.      Breath sounds (anterior/ posterior 6 pts., lateral)   vii.      Heart sounds (anterior 5 pts.)
    •      1.      Upper Extremities
    •      2.      inspect and symmetry
    • viii.      ROM and muscle strength 
    • ix.      Capillary refill                        
    • x.      Pulses
  49. Base line assesment parts:Part 13:
    Abdonim
    i.      symmetry and contour                                                 ii.      bowel sounds (all 4 quadrants)                                     iii.      Palpate all 4 quadrants for masses, organmegally, tenderness
  50. Base line assesment parts:
    Part 14: Lower extrematies
    • i.      Symmetry and skin                                                  ii.      Pulses (popliteal, tibial, dorsalis pedis, posterior tibialis)    
    • iii.      Palpate for edema                                                  iv.      Check homan’s sign bilaterally (Push foot back to test for pain in calf)                                                            v.      Test ROM                                                           vi.      Capillary refill
  51. Base line assesment parts:
    Part 14: Musculiskeletal
    i.      Note muscle strength when testing extremities                                                      ii.      Deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles)
  52. Medical Asepsis
    cleantechniques. Includes procedures used to reducethe number of and prevent the spreadof microorganisms. Ex. Washing hands, barrier techniques, etc.
  53. Surgical Asepsis:
    a.       Sterile techniques. Includes the procedures to eliminate all microorganisms from an area. Ex. OR, labor and delivery, etc.
  54. Pathogenic organisms
    microorganismscapable of causing disease
  55. Chain of infection
    • I.                   Infectious agent: Microorganism(s) that can make you sick (Pathogenic organisms)
    • II.                Reservoir: A place where microorganisms survive, multiply, and wait to transfer to a susceptible host.
    • III.             Portal of Exit: Skin, mucous membranes, respiratory tract, etc.
    • IV.             Modes of Transmission: Airborne, droplets, contact, vesicle, vector.
    • V.                Portal of Entry: broken skin, mucous membranes, genitourinary and gastrointestinal tracts, etc.
    • VI.             Susceptible Host: any individual. Immune system helps make less susceptible.
  56. What can a nurse do to break the chain of infection?
    • Hand washing
    • asepsis techniques
    • bed changing
    • washing areabefore injection, etc.
  57. Bacteria:
    • one-celledmicroorganisms capable of multiplying rapidly within a susceptible hoast 
    • Bacterial infections are treated with antibiotics.
  58. Virus
    • microorganisms that cause significant morbidity
    • Becausereplication of the virus occurs within the host cell, killing the virus withoutharming the host cell is seldom possible. Prevention (immunizations, hygiene) is still the best way to combatviral illness.
  59. Nosocomial/HAI’s
    • HAI - health accuied infections
    • Patientsin health care settings often have multiple illnesses, are older adults, andare often poorly nourished.  Thesefactors make them more susceptible to infection.  Also invasive treatment devices such as IV’sor indwelling urinary catheters impair or bypass the body’s natural defensesagainst microorganisms.  Theconscientious practice of hand hygiene and aseptic technique reduces the riskfor HAI’s.  Urinary tract infections arethe most common of the HAIs. HAIs are much more serious than
  60. Epidermis
    epidermis,which is the most outermost layer.  Thebase of the epidermis continually produces new cells to replace those at thesurface.
  61. Dermis
    whichis strong connective tissue that contains nerve endings, sweat glands, and hairroots, is well supplied with blood vessels
  62. subcutaneous layer
    liesbeneath the dermis.
  63. Tree layers of the skin
    • Epidermis
    • Dermis
    • Subcutaneus
  64. Nail care
    • a.       Nails reflects general health state of  nutrition… there is strong evidence to support the fact that artificial nails, long nails, and nails with nail polish harbor an increased number of microorganisms.  Long nails also carry more pathogens than short well manicured nails. Cracked nail polish is another area on the body with increased microorganisms.                                 
    • i.      Nursing practices
    • 1.      Use hand gel correctly to ensure maximum antibacterial effect
    • 2.      Proper had hygiene, including the use of alcohol hand gels, helps to prevent transmission of infections to health care workers and patients.                                      ii.      Do not wear long, polished, or artificial nails in patient care settings                                                          iii.      Keep nails well manicured, and free of rough edges, hangnails, or cuticle cuts.
    • b.      Normal nail approximately 160 degree angle between nail plate and nail.
    • c.       * Koilonychia (spoon Nail) Concave curves… Causes: Iron deficiency anemia
  65. a.      male Peri Care
    • i.      fill the bath basin with clean water at 110 degrees,
    • ii.      position the male patient on their back,     
    • iii.      put a protective cover over the bed linen,    
    • iv.      wash the groin from the front to the back starting at the groin area and then going to the inside of the thighs, 
    • v.      then rinse the cloth or use a new washcloth,
    • vi.      pull back the foreskin if the patient is not circumcised,    
    • vii.      wash and rinse the tip of the penis downward while using gentle, circular motions and then the scrotum,        
    • viii.      rinse the cloth,
    • ix.      turn the person on their side,
    • x.      And wash, rinse and dry the rectal area.
  66. female Peri care
    • i.      fill the bath basin with clean water at 110 degrees,  
    • ii.      position the female patient on their back,    
    • iii.      put a protective cover over the bed linen,
    • iv.      separate the labia and wash, rinse and dry the urethral area first with short downward strokes alternating from side to side and proceeding until the exposed area around the urethra is done,    
    • v.      then rinse the cloth or use a new washcloth,  
    • vi.      wash the groin on the outside of the labia from the front to the back starting outside the labia and then going to the inside of the thighs,
    • vii.      then rinse the cloth, 
    • viii.      turn the person on their side,
    • ix.      And wash, rinse and dry the rectal area.
  67. Dentures
    • 1.  With washed and gloved hands, remove or have the person remove their dentures. If you are removing them, it is best to hold the upper denture and gently pull them down and out of the mouth. To remove the lower denture, hold them and gently pull them up out of the mouth.
    • 2.      Place the dentures in the emesis basin or denture cup.
    • 
3.      Line the sink with a paper towel or water to help avoid any denture breakage should you drop them
    • .
4.      Run cool or room temperature water. Do NOT use hot water. Hot water can damage dentures.
    • 
5.      Rinse the dentures.

    • 6.      gently brush the dentures using a toothbrush and toothpaste while holding them safely and firmly in your hand.

    • 7.      Rinse the dentures under the running water.

    • 8.      Place the dentures in a denture cup or emesis basin with cool water or mouthwash until they are put back in the person's mouth after mouth care.
  68. Normal Vs. Abnormal mouth/ lips
    • Normal; lips are pink, moist, symmetrical, without leasons, smooth
    • Abnormal: Anemia causes palor, Cyanosis caused by respiratory problems, leisons, such as nodules, or ulcerations can be related to infection, irritation, or skin cancer. 
  69. 1.      Unconscious patient care
    • a.       Always remember to talk to and explain producers to unconscious patients because they can still hear you. (watch what you say)
    • b.       Always maintain patient’s privacy and you are your patient’s advocate.
    • c.       When taking temperature use a temporal or tympanic thermometer. NEVER use an oral thermometer on unconscious patient.
    • d.      Make sure to change and reposition patients often in order to prevention and decrease pressure ulcers.
    • e.       Keep patient’s bed clean, and dry. If patient’s bed becomes dirty, or wet. Make an occupied bed.
    • f.        Oral Hygiene for unconscious patient (pg.767 or skill on pg. 789b)
    • g.      Patients who are unconscious or have artificial airways are susceptible to excessive drying of salivary secretions because they are unable to eat or drink, frequently breathe through the mouth or have their mouths open, and often receive oxygen therapy, which has a drying effect on the mucosal surfaces. In addition, the unconscious patient does not sallow salivary secretions, resulting in accumulation of secretions in the mouth. These secretions often contain gram negative bacteria that cause pneumonia if aspirated in the lungs. Topical chlorhexidine is acceptable for use in oral care, especially in patients on ventilators in the acute setting. Current evidence shows a one-time use of chlorhexidine with oral hygiene reduces the risk for ventilator-associated pneumonia. Unconscious patients need special attention because they don’t have a gag reflex. Proper oral hygiene requires keeping the mucosa moist and removing secretions that lead to infection. While providing hygiene to an unconscious patient, you need to protect the patient from choking and aspiration. The safest way to provide oral care is with two nurses, or one nurse and a CNA. One nurse does the cleaning while the other removes secretions with suctioning equipment.  When cleansing the oral cavity, use a padded tongue blade, or small airway to hold the mouth open. NEVER use your fingers.  As you clean the patient oral cavity explain the steps and sensations the patient will feel during the cleaning. Tell patient when the producer is done.  Research states that foam stick applicators stimulate the mucosal tissues however; they don’t remove debris from the teeth. Pediatric toothbrushes are better at removing plaque and tartar and it fits better around an endotracheal tube.
  70. Charicteristics of Pedicluosis capitis (Head lice)
    Tiny grayish white parasitic insects that attach to hair strands; eggs look like oval particles; resemble dandruff; bites or pustules often found behind ears at hairline.
  71. Implications of Pedicluosis capitis (Head lice)
    Head lice are difficult to remove and if not treated will spreadto furniture and other people
  72. Interventions for Pedicluosis capitis (Head lice)
                                                                  i.      : Check entire scalp. Use a special lice comb to remove lice and nits. The National Pediculosis Association encourages a nonchemical approach with manual removal whenever possible. Caution against use of products containing lindane because the ingredient is a neurotoxin known to cause adverse reactions ranging from dermatitis to seizures and death. Check the hair for nits, and comb with a nit comb for 2 to 3 days until all lice and nits have been removed. Vacuum infested areas of home and car upholstery.
  73.  Pediculosis corporis (Body lice) Characteristics:
     Tend to cling to clothing, making them difficultto see; body lice suck blood and lay eggs on clothing and furniture.
  74. Pediculosis corporis (Body lice)Implications:
           Implications: Patient itches constantly; scratches on skin become infected; hemorrhagic spots appear on skin where lice are sucking blood.
  75. Pediculosis corporis (Body lice)
         Interventions: Have patient bath or shower thoroughly; after drying skin, apply lotion for eliminating lice; after 12 to 24 hours have patient take another bath or shower; bag infested clothing or linen until laundered.
  76. a.       Pediculosis pubis ( Crab lice) Characteristics:
    •    Characteristics: Found
    • in pubic hair; crab lice are grayish white with red legs.
  77. a.       Pediculosis pubis ( Crab lice) Implications:
     Lice spread through bed linen, clothing, furniture, or sexual contact
  78. a.       Pediculosis pubis ( Crab lice) Interventions
    : Shave hair off affected areas; cleanse as for body lice; if lice were sexually transmitted, patient needs to notify partner.
  79. 1.      How does a corticosteroid work?
      Corticosteroids suppress migration of polymorphonuclear leukocytes (PML), or neutrophil granulocytes and reverse increased capillary permeability by their anti-inflammatory effect.  Suppress immune system by decreasing activity of lymphatic system.
  80. Rightvs. Wrong size of B/P Cuff – what does it mean
    • Cuff too Big: B/P too low (false low reading)
    • Cuff too Small: B/P too high (false high reading) 
  81. OrthostaticHypotension
    a.       : reduction of systolic B/P of at least 20 mmHg and reduction of diastolic B/P of at least 10 mmHg within 3 minutes of quiet standing.
  82. when does Orthostatic Hypotension occur?
    Drop in B/P seen when patient changes position from supine, to sitting, to standing. Occurs when the peripheral blood vessels in the legs are already constricted or are unable to constrict in response to change in position.
  83. Signs and syphtoms of orthostatic Blood Pressure
    : dizziness, lightheadedness, sudden pallor, weakness, and/or feeling faint with change of position- severe cases result in loss of consciousness upon change of position
  84. Hot to test for Orthostatic Hypotention
    • 1.      Supine: Take B/P on both arms. Record highest reading. Leave B/P cuff in place. Assist pt to sitting position. Wait 1-3 minutes. If orthostatic s/s occur (pt gets light-headed, dizzy, etc.) assist pt back to supine position
    • 2.      Sitting: Take B/P on both arms after waiting 1-3 minutes. Record highest reading. Assist pt to standing position. Again, if orthostatic s/s occur return pt to supine position
    • 3.      Standing: Take B/P on both arms after waiting 1-3 minutes. Record highest reading. Again, if orthostatic s/s occur, return pt to supine position.
    • 4.      Record pt’s B/P in each position: if orthostatic B/P will change with each reading. For example: 140/80 supine, 132/72 sitting, 108/60 standing
    • 5.      Report findings to charge nurse or health care provider
  85. Orthostatic Hypotension Risk Factors:
    • Fluid volume deficit from decreased blood volume
    •  Dehydration
    • Recent blood loss
    • Prolonged bed rest
    • Anemia
    • Antihypertensive meds
  86. Can orthostatic B/P Measurment be deligated to a CNA?
    NO! you knuckle head!
  87. Bed Bath Do's And Dont's
    • Do: ·        
    • Review orders for special precautions concerning pts movement or positioning·        
    • Provide Privacy! Cover pt with bath sheet, towels, etc. Close door, pull curtain, etc.·        
    • Adjust room temperature to make pt comfortable·         Check water temperature – allow pt to test water temp.·        
    • Take special care to wash and dry skin folds underneath breasts and other areas where skin to skin contact·         Assess skin for breakdown, dryness, redness, swelling, etc.·        
    • Use side rails to prevent pt falling·        
    • Raise bed to promote good body mechanics for yourself·        
    • Change water often to keep temp warm and from getting too soapy
    • DONT's :
    • Leave the window blinds open!·          
    • Disconnect IV tubing when undressing pt·        
    • Soak feet if pt has diabetes or peripheral vascular disease·        
    • Use long firm strokes to wash the lower extremities of pts with history of deep vein thrombosis or blood clotting disorder·        
    • Massage or rub back of the calf muscle –could dislodge a deep vein thrombus
  88. Macule
    a.      Flat, nonpalpable change in skin color than 1.0 cm (e.g. Freckle, petechia)
  89. Papule
    a.      Palpable circumscribed, solid elevation in skin, smaller than 0.5 cm (e.g. Elevated nevus)
  90. Nodule:
    a.      Elevated solid mass, deeper and firmer than papule, 0.5 to 2.0 cm (e.g. wart)
  91. Tumor:
    Solidmass that extends deep through subcutaneous tissue, larger than 1.0 to 2.0 cm(e.g. epithelium)
  92. Wheal
    a.      Irregularly shaped, elevated are or superficial localized edema, varies in size (e.g. hive, mosquito bite)
  93. Vesicle
    a.      Circumscribed elevation of skin filled with serous fluid, smaller than 1.0 cm (e.g. herpes simplex, chickenpox)
  94. Pustule
    a.      circumscribed elevation of skin similar to vesicle but filled with pus, varies in size (e.g. acne, staphylococcal infection)
  95. Ulcer
    Deep loss of skin surface that sometimes extends to dermis and frequently bleeds and scars, varies in size (e.g. venous stasis ulcer)
  96. Atrophy
    Thinning of skin with loss of normal skin furrow with skin appearing shiny and translucent, varies in size (e.g. arterial insufficiency)
  97. PERRLA
    a.       Pupils Equal, Round and Reactive to Light and Accommodation
  98. PERRLA the overinformed version:
    • a.       Pupils Equal, Round and Reactive to Light and Accommodation                                                             
    • i.      Pupils are normally black, round, regular and equal in size (3 to 7 mm in diameter). The iris should be clearly visible. Not the color and details of the iris.                                                            
    • ii.      Cloudy pupils indicate cataracts. Dilated pupils result from neurological disorders, glaucoma, trauma, eye medication, or withdrawal from opioids. Pinpoint pupils are a common sign of opioid intoxication.                                                          
    • iii.      When shining a beam of light through the pupil and onto the retina, this stimulates the third cranial nerve and causes the muscles of the iris to constrict.                                                          
    • iv.      Test papillary reflexes (to light and accommodation) in a dimly lit room. While the patient looks straight ahead, bring a penlight from the side of the patient’s face, directing the light onto the pupil. If the patient at the light there will be a false reaction to accommodation. A directly illuminated pupil constricts, and the opposite pupil constricts consensually. Observe the quickness and equality of the reflex. Repeat of the other side                                                            
    • v.      To test accommodation, ask the patient to gaze at a distant object (the far wall) and then at a test object (finger or pencil) held approximately 10 cm (4 inches) from the bridge of the patient’s nose. The pupils normally converge and accommodate by constricting when looking at close objects. The pupil responses are equal. If assessment of papillary reaction is normal in all tests, record the abbreviation PERRLA
    • 1.      Check for
    • a.       Visual acuity
    • b.      Photophobia (can’t tolerate light)
    • c.       Diplopia
    • d.      PERRLA
    • e.       EOM – extra ocular movements
    • f.       Nystagmus – involuntary movement of the eye due to injury
    • g.      Eyelids, conjunctiva and sclera
    • h.      Ear to eye alignment
  99. Normal Nail:
    Approximately 160 degree between nail plate and nail.
  100. .The semilunar, whitish area at the base of the nail bed is called the _____________
    lunula
  101. Themost visible portion of the nails is the __________
    nail Plate
  102. Capilary refill on nail beds..
    a.      To palpate, gently grasp the patient’s finger and observe the color of the nail bed. Next, apply gentle, firm, quick pressure with the thumb to the nail bed and release and observe capillary refill. As you apply pressure, the nail bed appears white or blanched; however, the pink color should return immediately on release of pressure. You measure capillary pressure in seconds; less than 2 seconds is brisk, whereas greater than 4 seconds is sluggish.
  103. Clubbing of the nail
    change in angle between nail and nail base (eventually greater than 180 degrees); nail bed softening, with nail flattening; often, enlargement of fingertips
  104. Beau’slines:
    Transverse depressions in nails indicating temporary disturbance of nail growth (nail grows out over several months)
  105. Koilonychia(spoon nail):
    • concave curves
    • 1.      Causes: Iron deficiency anemia, syphilis, use of strong detergents
  106. Splinterhemorrhages
    • red or brown linear streaks in nail bed
    • 1.      Causes: Minor trauma, subacute bacterial endocarditis, trichinosis.
  107. Paronychia
    • : Inflammation of skin at base of nail
    • 1.      Causes: Local infection, trauma
  108. Crackles
    • Most commonly Asculated in: dependant lobes
    • Cause: Random, sudden reenflation of groups of alveoli; disruptive passage of air through small airways
    • Character: CRACKLE SOUNDS
  109. Ronchi (sonorus wheese)
    • primarily heard over trachea and broinchi; if loud enough, can be heard over most lung fields
    • Cause ; muscle spasms, fluid, or mucous in larger airways
    • Character: Rumbleing coarse sound
  110. Wheezes, (sibilant wheeze)
    • Heard ofer all lung fields
    • Cause: High - vilosity airflow through severely narrowed obstructed airway
    • Character: High pitches continuous muscle sounds like  asqueek heard continuously during insperation or resperation
  111. Plural friction rub
    • Heard over anterior lateral lung field (if patient is sittiing uprite)
    • Cause: Inflamed pleura, parietel pleura rubbing against visceral pleura
    • Character: Has a dray grating qulaity during resperation, does not clear through coughing
  112. S1 and S2 --- where are you?
    • S1 is the LUB
    • S2 is the DUB
    • in LUB DUB.
  113. Heart Assesment, what are the five areas? -- in order of assesment
    • Aortic
    • Plumonic
    • Second Plumonic
    • Tricuspid
    • Mitral
  114. Where is the Aortic Area?
    Second intercostal space on the right lateral boarder of the sternum
  115. Where is the Pulmonic Area?
    Second intercostal space on the Left lateral boarder of the sternum
  116. Where is the second Plumonioc area?
    Left sternal border,thirs intercostal space
  117. Where is the tricuspid area?
    forth - fith intercostal space along the left lateral boarder of the sternum.
  118. Where is the Mitral, or apical   area?
    fith intetrcostal space, mid clavicular line
  119. Sitting position
    • Sitting upright provides full expansion of lungs and provides better visualization of symmetry of upper body parts.  Physically weakened patient is sometimes unable to sit.  Use supine position with head of bed elevated instead.
    • Used to exzmine head, and neck, back , posterior thorax and lungs, breast axilae,heart vital signs and upper extrematies.
  120. Supine
    • Veryrelaxed position.  It provides easy accessto pulse sites
    • Used to asses the head and neck, tha anterior thorax, the lungs, breasts, axillae, heart, abdomin, extematies, pulse
  121. Dorsal recumbant
    • Greatposition for abdominal assessment because it promotes relaxation of abdominalmuscles.  Patients with painful disordersare more comfortable with knees flexed.
    • asses head and neck, anterior thorax, and lungs, breasts axilae, heart, abdomin
  122. Lothotomy
    • Providesmaximal exposure of genitalia and facilitates insertion of vaginalspeculum.  It is embarrassing anduncomfortable, so minimize time spent it position, and keep patient welldraped.
    • female genatalia, and genital tract
  123. Sims
    • a.       -(Enema position).  Exposes rectal area.  Pt. with joint deformities might have problems bending hip and knee.
    • Asses rectum and vagina
  124. Prone ,
     Helps to assess extension of hip joint, skin, and buttocks.  Patient with respiratory difficulties do not tolerate this position well.Asses musculoskeletal system
  125. lateral recumbant
    Aids in detecting murmurs.  Patients with respiratory difficulties do not tolerate well.asses heart
  126. Knee chaest
    a.       This position provides maximal exposure to rectal area.  This position is embarrassing and uncomfortable. 
  127. Dorsal recumbant
  128. Knee chest
  129. lateral recumbant
  130. lothotomy position
  131. Prone
  132. Sitting Positon
  133. Supine
  134. Abdominal assessments vs. regular assessments
    a.      Begin with INSPECTION THEN AUSCULTATION. By using auscultation before palpation, there is less chance of altering the frequency and character of bowel sounds.
  135. Bluish(Cyanosis)
    -condition - causes - Assesment location -
    • Condition - Increasedamount of deoxygenated hemoglobin (associated with Hypoxia
    • Causes - Heartor lung disease, or cold environment
    • Assesment location - Nailbeds, lips base of tongue, skin(severe cases)
  136. Pallor(decrease in color
    -condition - causes - Assesment location -
    • Condition  - 1 Reduced amount oxyhemoglobin 2 Reduced visibility of oxyhemoglobin resulting from decreased blood flow
    • Causes  - 1 Anemia  2 Shock
    • Assesment location  - 1 Face, conjunctiva, nail beds, palms of hands 2 Skin, nail beds, conjunctiva, lips
  137. Loss of pigmentation
    -condition - causes - Assesment location -
    • Condition - Vitiligo
    • Causes - Congenital   or autoimmune condition causing lack of pigment
    • Assesment Location - Patchyareas on skin over face, hands and arms
  138. Yellow-orange(Jaundice)\
    -condition - causes - Assesment location -
    • Condition - Increased   deposit of bilirubin in tissues
    • Causes -Liver   disease, destruction of Red blood cells
    • Assesment Location - Sclera,mucous membranes
  139. Red(erythema)
    -condition - causes - Assesment location -
    • Condition - Increased   visibility of oxyhemoglobin caused by dilation of increased blood flow
    • Causes - Fever,   direct trauma, blushing, alcohol intake
    • Assesment Location - Face,   area of trauma, sacrum, shoulders, other common sites for pressure ulcers
  140. Tan-Brown
    condition - causes - Assesment location -
    • Condition - Increased   amount of melanin
    • Causes - Suntan,   pregnancy
    • Assesment location  - Areas   of exposed to sun: face, arms, areolae, nipples

  141. What is this?
    Posterior thorax excursion
  142. 1.      Chest excursion (aka. Posterior thoracic excursion) is done how?
  143. Stand       behind the patient and place the thumbs along the spinal process at the       tenth rib with palms slightly contracting the posterior lateral       surface.  Place thumbs 5cm or 2 inches apart, press hands towards       spine so that a small skin fold appears between the thumbs DO NOT SLIDE       THE HANDS Instruct the patient to take a deep breath after exhaling. Movement ofthe thumbs should be symmetrical, separating the thumbs 3 to 5 cm or one andone forth
  144.  What is tactile fremitus?
    That wierd thing we did where the person says "ninety nine" while you feel their back - used to asses if the resonation is equal on both lungs
  145. What is edema?
      : is a area of skin that becomes swollen or edematous from fluid buildup in the tissue
  146. What i sedema pitting, how is it assesed?
    • a.       Edema pitting: When pressure from your fingers leaves an indentation in the edematous, to assess pitting edema press the edematous area firmly with your thumb for several seconds and release.
    • a.       The depth of edema is measured in millimeters, this determines the degree of edema (example +1 edema equals 2mm and +2 equals + 4mm see ( page 347 15-410) 
  147. 1.      Antipyretic meds
    • Antipyretics – Drugs that reduce fever and generally orderedby health care providers if a fever is over 102.2 degrees.
    • Ex.
    • -Acetaminophen (Tylenol)    
    • - Salicylates (Aspirin)    
    • - Indomethacin (nonsteroidalanti-inflammatory)    
    • - Ibuprophen    
    • - Keterolac (nonsteroidalanti-inflammatory)a.       Corticosteroids reduce heat production by interfering with the hypothalamic response. These drugs mask signs of infection by suppressing the immune system. Thus patients on steroids need to be observed closely, especially if they are at risk for infection. Corticosteroids are not used to treat a fever. However, it is important to be aware of their effect on suppressing the ability of the patient to develop a fever in response to bacterial or viral infection.
  148. 1.      Testicular self-exam, what to look for
    a.       (what to look for) – Testicular cancer is a soled tumor commonly found in young men ages 18 – 34 years. Early detection is critical. The most common symptoms of testicular cancer are a painless enlargement of one testis and appearance of a palpable small, hard lump about the size of a pea on the front or side of the testicle.
  149. a.       Teaching strategies (provide information to all male patients 15 years and older
    •                                                              
    • i.       perform exam monthly after a warm bath or shower (when scrotal sac is relaxed and less thick).                                                           
    • ii.      Stand naked in front of a mirror holding the penis in your hand and examine the head. Pull back the foreskin if uncircumcised to expose the glands.                                                          
    • iii.      Inspect and palpate the entire head of the penis in a clockwise motion, looking carefully for any bumps, sores, blisters, or unusual discharge. Blisters and bumps may be light colored or red and resemble pimples.                                                         
    • iv.      Look for genital warts.                                                           
    • v.      Look at the opening (urethral meatus) at the end of the penis for discharge.                                                        
    •   vi.      Look long the entire shaft of the penis for the same signs.                                                       
    • vii.      Be sure to separate pubic hair at the base of the penis and carefully examine the skin underneath.
  150. 1.      DTRs
    Deep tendon reflexes): Eliciting reflexes demonstrates integrity of sensory and motor pathways. There are deep tendon reflexes, elicited by mildly stretching a muscle and tapping a tendon, and cutaneous reflexes elicited by stimulating the skin superficially. 
  151. HIPAA
    a.       Health Insurance Probability and Accountability Act
  152. EES
    erthromyosin
  153. STI
    SexuallyTransmitted Infection
  154. RUQ
    RightUpper Quadrant
  155. RLQ
    RightLower Quadrant
  156. LUQ
    LeftUpper Quadrant
  157. LLQ
    LeftLower Quadrant
  158. q4h
    a.       every 4 hours
  159. NICU
    NeonatalIntensive Care Unit
  160. CDC
    a.       CDC: Center for Disease Control and Prevention
  161. BUN
    a.       BUN: Blood Urea Nitrogen
  162. ABG
    a.       ABG: Arterial Blood Gas
  163. tid
    a.       tid: three times a day
  164. pc
    a.       pc: after meals
  165. dx
    a.       dx: diagnosis
  166. c/o
    a.       c/o: complaint of
  167. s
    a.       s(with a line over it): without
  168. ECG oer EKG
    a.       ECG or EKG: Electrocardiogram
  169. CNS
    a.       CNS: Central Nervous System
  170. tx
    a.       tx: treatment
  171. stat
    a.       stat: immediately or at once
  172. a.       ROM: Range of Motion Exercises
    ROM
  173. rx
    a.       Rx: prescription
  174. qid
    a.       qid: four times a day
  175. Npo
    a.       NPO: Nothing by mouth
  176. GI
    a.       GI: gastrointestinal
  177. DNR
    a.       DNR: Do Not Resuscitate
  178. CHF
    a.       CHF: Congestive Heart Failure
  179. CA
    a.       CA: cancer
  180. CBC
    a.       CBC: Complete Blood Count
  181. c
    a.       c (with a line over it): with
  182. BRP
    a.       BRP: bathroom privileges
  183. BM
    a.       BM or bm: bowel movement
  184. a.       bid: twice a day
    bid
  185. WNL
    a.       WNL: Within normal limits
  186. prn
    a.       prn: when necessary
  187. D&C
    a.       D&C: dilation & curettage
  188. TKO
    a.       TKO: To Keep Open
  189.    AMI:
    a.       AMI: Acute Myocardial Infarction
  190. LMP
    a.       LMP: Last Menstrual Period
  191. PERRLA
    a.       PERRLA: Pupils Equal, Round, and Reactive to Light Accommodation
  192. ASA
    a.       ASA: aspirin
  193. r/o
    a.        r/o: rule out
  194. COPD
    a.       COPD: Chronic Obstructive Pulmonary Disorder
  195. HAI
    a.       HAI: Hospital Associated or Acquired Infection
  196. BSE
    a.       BSE: Breast Self Exam
  197. LOC
    a.       LOC: Level of Consciousness

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