Assessment Final

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Assessment Final
2010-06-12 15:17:20
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  1. Review of Symptoms
    evaluate past and present health states of each body system; head-to-toe exam; note presence or absence of symptoms; subjective data only
  2. symptoms- way to characterize
    • OPQRST
    • onset, pain/palliation, quality, region/radiation, severity, time
  3. Sleep (importance/description)
    rest, re-energize; ask pt. if they take naps, any insomnia, PND-paroxysmal nocturnal dyspnea, nocturia, SOB, light sleep
  4. Intimate partner violence
    • ask every woman if she has been abused by husband/boyfriend. Abuse Assessment Screen (AAS)-routine questions to screen for violence
    • 1- when you and partner argue are you afraid of them?
    • 2- when you and paertner verbally arugye, do you think they try to emotionally hurt/abuse you?
    • 3- does your partner try to control you?
    • 4- has your partner or anyone else ever slapped you, pushed you, hit you, kicked your or otherwise physically hurt you?
    • 5- since you have been pregnant, has your partner ever bit you, slapped you, pushed you, hit you, kicked you, or otherwise physically hurt you
    • 6-has your partner ever forced you to have sex?

    if yes, ask to share more.
  5. Inspection in physical assessment
    • inspection is concentrated watching and ALWAYS comes FIRST
    • use your sense
    • close, careful scrutiny of the individual as a whole then of each body system
    • inspection begins the moment you first meet the person
    • a focused inspection takes time
    • requries good lighting, adequate exposure, occasional use of instruments to enlarge view
    • (inspection, palpation, percussion,auscultation)
    • objective data
  6. weight in the pt
    • cechetic/emaciated- very thin showing bone structures, as in cancer pts
    • simple obesity- even fat distribution
    • centipetal (truncal) obesity- fat in the neck, trunk and thin extremities (cushings syndrome)
    • there is weight loss in acute disease- "unexplained weight loss with short term illness"
    • remove shoes and heavy outer clothing to properly weigh pt
    • when having to weigh every day, try to do it at the same time each day with same type of clothing
    • measured in kilograms and pounds
    • obesity is >120% of ideal body weight. may be due to endocrine disorder, drug therapy, mental depression
  7. BMI- body mass index
    • <18.5 underweight
    • 18.5-24.9 normal
    • 25-29 overweight
    • 30-39.9 obesity
    • >40 extreme obesity
  8. waist circumference
    >35 in women and >40 in men= increase risk cardiovascular and metabolic diseases
  9. stroke volume
    • an amount of blood pumped by the heart with each beat
    • ~70ml in the adult

    CO=SVxR cardiac output= stroke volume x rate
  10. BP ranges, characteristics
    • systolic- maximum pressure felt on artery during L ventricular contraction; systole
    • diastolic- pressure the blood exerts constantly between contractions
    • MAP-mean arterial pressure- pressure forcing blood into the tissues averaged over the cardiac cycle
    • gradual rise through childhood and into adult years
    • female adults have <BP than male adults
    • Black pt BP usu. higher than white of same age
    • <=120/80 normal
    • 121-139/81-90 pre-hypertension
    • 140-159/90-99 hypertension
    • 160/100 severe hypertension
    • causes of chaneges= diurnal rythm, weight, exercise, emotions,stress
  11. Aging adult vitals
    • physical appearance- by 8th-9th decade body contour is sharper,more angular features, redistrubted body proportions
    • posture-
  12. Pain
    • all pain is neurogenic
    • SLIDTA:severity, location,intensity,duration,type,associated factors
  13. sources of pain:
    • cutaneous :skin/scalp/teeth
    • somatic: muscle/bone/ligament
    • viscera: kidneys/pancreas/organs
    • neuropathic:central and
    • peripheral nervous system
  14. Nociception:
    • term used to
    • describe how noxious stimuli are perceived as pain (4
    • steps)
    • 1-transduction: injured tissue releases chemicals that propagate pain message, action potential
    • moves along an afferent fiber to the spinal cord
    • 2-transmission:pain impulse moves from spinal cord to brain
    • 3-perception of pain
    • 4-modulation:neurons from brain stem release neurotransmitters that block the pain impulse
    • neurotransmitters that propagate pain message: substance P, histamine, prostaglandins,
    • serotonin, bradykinin
    • pain is NOT normal in elderly; pain is indicative of a problem or disease
  15. types of pain by duration
    acute: short term, self limiting, follows predictable trajectory, dissipates after injury heals

    • chronic: persistent, pain continues for 6 months or more, can be malignant or non-malignant; does not stop when injury heals
    • -->malignant pain often parallels the pathology created by tumor cells; it is induced by tissue necrosis or stretching of an organ due to growing tumor
  16. neuropathic pain
    • is an abnormal processing of pain message
    • neuropathic pain will NEVER be in the brain because brain has NO pain receptors
    • neuropathic pain is fro damage to peripheral nerves or central nerves
    • neuropathic pain usu. found in diabetics
    • it is a type of pain that does not adhere to typical and predictable phases of nociceptive pain
    • the pain is perceived long after injury heals
    • pain is sustained on a neurochemical layer and cannot be identified by x-ray,CT scan; nerve conduction studies are neededm
  17. Wong-Baker Pain Scale
    • (pain scales are intended to reflect pain intensity)
    • used for children because they are incapable of self report, therfor the assessment is dependent on behavioral and physiological clues
    • rating scales can be introduced at 4 or 5 y/o
    • child is asked to choose the face that shows "how much hurt you have now?"
    • coded as: 0-5 or 0-10 (couting in 2's)
    • 0: no hurt
    • 1 or 2: hurts a little bit
    • 2 or 4:hurts a little more
    • 3 or 6: hurts even more
    • 4 or 8: hurts a whole lot
    • 5 or 10: hurts worst
  18. Optimal Nutritional Status
    sufficient nutrients consumed to support day to daty body needs AND any increased metabolic demands due to growth, pregnancy or illness
  19. undernutrition
    when nutritional reserves are depleted and or when nutrient intake is inadequate to meet day to day needs or added metabolic demands
  20. overnutrition
    caused by the consumption of nutrients, especially calories, sodium and fat in excess of body needs
  21. overweight definition in children
    BMI greater or equal to 95th percentile based on age and gender specifics
  22. overweight in adults
    BMI of 25 or more
  23. obese
    BMI of 30 or more
  24. severe obesity
    BMI of 40 or more
  25. at risk population for nutrition
    babies cant feed themselves

    aging adult may have socioeconomic issues and therefor a decline in nutrion
  26. aging affects that directly affect elderly
    • poor dentition, decreased visual acuity, decreased salica production, slowed fastrointestinal mitility, decreased fastrointestinal absorption, diminished olfactory and taste sensitivity
    • there is a decrease in nutritional requirements due to loss of lean body mass, the most metabolically active tissues and an increase in fat mass
  27. cultural awareness in nutrition restrictions
    • buddhism- no meat
    • catholicism- ash wednesday, good friday and other holy days have restrictions
    • hinduism-beef pork and some forms of fowl, alcohol, garlic and onions by some, red colored foods (tomatoes, etc)by some
    • islam-all pork and pork products, meat not slaughtered according to ritual, alcoholic beverages and products (vanilla extract),coffee and tea, food and beferages before sunset during Ramadan
    • mormon-alcoholic beverages, caffeinated beverages, medicines containing caffeine or stimulants or alcohol
    • othodox judaism-all pork/pork products, meat not slaughtered according to ritual, all shellfish, dairy products and meat at same meal, leavened bread and cake during passover, food and beverages on yom kippur
    • seventh day adventist- all pork/pork products, shellfish, meat/dairy products/eggs by some, alcoholic beverages, coffee and tea, highly seasoned foods
  28. purpose of nutritional assessment
    • 1- identify individuals who are amalnourisehed or are at risk of developing malnutrition
    • 2- provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition
    • 3- establish baseline data for evaluating the efficacy of nutritional care
  29. nutritional screening
    • may be completed in any setting, based on easily obtained data
    • weight, weight history, conditions associated with increased nutritional risk, diet information and routine laboratory data
  30. adolescent nutrition
    3 meals a day are not sufficient intake so snacks are good way to achieve enough intake
  31. infants and children nutrition
    children 2 and under should NOT drink skim or low fat milk because calories and fatty acids are needed for proper growth and development of the central nervous system
  32. comprehensive nutritional assessment
    dietary history and clinical information, physical examination for clinical signs, anthropometric measures and laboratory tests.
  33. 24 hour recall
    • easiest and most popular method for obtaining infomation about dietary intake
    • errors may occur when pt or family does not remember intake, they alter truth, snacks and gravies may not be recorded, intake may be different than usual intake
  34. pregnant nutrition
    • multiparous woman with pregnancies occurring less than one year apart has an increased risk of depleted nutritional reserves
    • recommended weight gain of 25-30 lbs for normal weight; 28-35 for underweight and 15-25 for overweight
  35. BMI
    • <18.5 = underweight
    • 18.5-24.9 = normal weight
    • 25-29.9 = overweight
    • 30-39.9 = obesity
    • 40+ = severe obesity
  36. waist circumference
    >35 in women and >40 in men = increase risk of cardiovascular and metabolic diseases
  37. skinfold thickness
    • estimate of body fat stores or the extent of obesity or undernutrition
    • biceps, subcapsular, suprailiac skinfolds can be used but triceps skinfold (TSF) is most common
    • values 10% above or below = under or overnutrition respectively
  38. Midupper arm circumference (MAC)
    estimates skeletal muscle mass and fat stores
  39. midarm muscle area (MAMA)
    good indicator of lean body mass and skeletal protein reserves
  40. dexa scan
    measures bone density
  41. bia scan
    measures body composition
  42. measuring frame size
    elbow breadth = skeletal breadth and is most accurate method to measure to determine frame size
  43. hemoglobin
    • used to determin iron deficiency anemia
    • increased hemoglobin levels= polycethemia vera or dehydration
    • decreased hemoglobin levels= anemia, recent hemorrhage, hemodilution by fluid retention
  44. hematocrit
    • measure of cell vloume, also indicator of iron status
    • low value=low hemoglobin formation
  45. cholesterol
    • measured to evaluate fat metabolism and assess risk of heart disease
    • normal= 120mg/dl-200mg/dl
  46. triglycerides (TG)
    • used to screen for hyperlipidemia and to determine risk of heart disease
    • these are age related
  47. total lymphocyte count (TLC)
    • most common used test of immune function
    • important indicator of visceral protein status
  48. skin testing
    • to verify immunity to antigens
    • test is positive if response is 5mm or greater-commonly candida, tetanus, diptheria,strep,tuberculin,proteus,trichophyton
    • positive= malnutition, hepatic falure, infection and immunosuppressive drugs
  49. serum albumin
    • measurement of visceral protein status
    • normal serum albumin in children older than 6 months and adults ranges from 3.5-5.5g/dl
    • low levels= protein/calorie deficiency, dehydration, decreased liver function
    • <2.8g/dl = severe depletion
    • consider persons history if this number is off because it can easily be altered
  50. Marasmus
    • protein-calorie malnutrition, prolonged starvation
    • anorexia, bowel obstruction, cancer cachexia, chronic illness lead to marasmus
  51. kwashirkor
    • protein malnutrition
    • diets that contain little or no protein
    • decreased visceral protein levels depressed immune function
    • appear well nourished/edematous
  52. marasmus/kwashiorkor mix
    • severe starvation
    • emaciated appearance
    • muscle and fat wasting
    • from major surgery, trauma, burns in combo with prolonged starvation
    • high risk of mortality
  53. magenta tongue
    riboflavin deficiency/vitamin b-complex
  54. metabolic syndrome (MetS)
    • 3 or more risk factors present
    • 1- fasting plasma glucose >/= 110mg/dl
    • 2-BP >/=130/85
    • 3-waist circumference of >/= 40 for men and 35 for women
    • 4-high density lipoprotein (HDL) cholesterol <40 in men and <50 in women
    • 5-triglyceride levels>/=150mg/dl
    • associated with increased risk for hearty disease, DM type 2, mortality
    • 28% prevalence in adolescents and 22% in adults
  55. moles
    • Change in mole regular size, irregular, pigmentation, lesions, asymmetry, more than 6
    • cm, itching, burning, or bleeding
    • ABCDE:
    • Asymmetric
    • Border
    • Color
    • Diameter
    • Elevation and Enlargement
  56. skin holds information, what does it tell you?
    holds information on the bodys circulation, hydration, signs of systemic disease
  57. skin neoplasms
    majority are result from occupational or environmental agents
  58. causes of unprotected skin exposure to sun
    • ages the skin earlier, causes lesions (primarily skin cancer)
    • those more at risk are light-skinned people and those over 40 and those regularly in the sun with no protection
  59. alopecia
    • hair loss
    • alopecia areata is hair loss in the form of small circular patches-can be anywhere on the body
  60. melasma
    mask of pregnancy
  61. lanugo
    fine downy hair in newborns
  62. linea nigra
    increased pigmentation in the midline of the abdomen during pregnancy
  63. changes in skin of pregnant women
    bigger areolas, increased pigmentation in areolae, nipples and vulva, linea nigra, vascular spyders, palmar eythema, striae gravidum (stretch marks)
  64. changes in skin of aging adult
    • outer layer, stratum corneum, thins an flattens allowing chemicals easier access into the body
    • wrinkling occurs because the underlying dermis thins and flattens
    • loss of elastin, collagen, subcutaneous fat, reduction in muscle tone
    • skin more apt to tear, shear
    • sweat and sebaceous glands decrease secretion
    • wound healing is delayed
  65. senile purpura
    fradile skin where trauma may produce dark red discoloered areas
  66. function of the skin
    • protect
    • prevent penetrations
    • perceptions-sensory organ for touch, pain, temperature
    • temperature regulation
    • identigication- hair color, skin color, fingerprints
    • largest organ of the body
  67. two types of hair
    • vellus- covers most of the body, fine
    • terminal- coarser hair, grows on scalp, eyebrows, axilla, pubec area, face, chest
  68. hair
    • is vestigial-no longer needed for protection from cold or trauma
    • they are threads of keratin
    • shaft is visible protruding part
    • hair growth is cyclical
    • arrector pili-contract and make hair stand up
  69. epidermis
    thin but tough, stratifies into several layers
  70. stratum germinativum
    • basal cell layer, forms new skin cells
    • major ingredient is keratin
    • melanocytes (give skin color-melanin) are found here
  71. stratum corneum
    • outer horny cell layer of dead keratinized cells that are tinterwoven and closely packed
    • constantly being shed
    • epidermis is completely replaced every 4 weeks
  72. nails
    • hard plates of keratin
    • pink color is from underlying vasculature
    • lunula is white opaque half moon that lies over the area that new cells are formed
  73. subcutaneous layer of skin
    fat tissue, provides insulation,cushion effect
  74. dermis layer of skin
    contains sebacous glands, sweat glands, arrector pili, hair follicle
  75. nail clubbing
    • Clubbing of nails occurs with congenital chronic cyanotic heart disease
    • and with emphysema and chronic bronchitis, and is greater than 180 degrees.
  76. erythema
    happens with fever, local inflammation, emotional reactions
  77. jaundice
    yellowing of the skin due to increased serum bilirubin from liver inflammation or hemolytic disease such as after severe burns or some infections
  78. icteris
    jaundice in the sclera of the eye
  79. basal cell carcinoma
    usually stars as a skin colored papule, with translucent top and overlyig telangiectasia. then develops rounded pearly borders with central red ulcer. looks like large open pore with central yellowing, most common form of skin cancer, slow but inexorable growth
  80. squamous cell carcinoma
    • Squamous Cell Carcinoma is erythematous scaly patch with sharp margins, 1cm or more.
    • Usually on hands or head, areas exposed to solar radiation. Less common than
    • basil cell carcinoma but grows rapidly.
  81. malignant melanoma
    • forms from preexisting nevi; usually brown but can be any color, even mixed
    • pigmentation; maybe scaling, flaking, oozing
  82. meningitis
    • inflammation of the membranes (meninges) and cerebrospinal fluid surrounding your brain and spinal cord, usually due to the spread of an infection. The swelling associated with meningitis often triggers the "hallmark" symptoms of this condition, including headache, fever and a stiff neck. Most cases of meningitis are caused by a viral infection, but
    • bacterial and fungal infections also can lead to meningitis. Depending on the cause of the infection, meningitis can resolve on its own in a couple of weeks— or it can be life-threatening
  83. Parotid gland
    • The largest of the three pairs of salivary glands. It lies within the cheeks in the front of the ear extending from zygomatic arch down to the angle of the jaw. It secretes saliva from its duct, Stensen’s duct, which runs forward to open on the buccal mucosa opposite the second molar.
  84. Bruits
    Occurs with accelerated or turbulent blood flow. In the thyroid gland, indicates hyperplasia of the thyroid (e.g.hyperthyroidism). In the vascular system p.540: a bruit occurs with partial occlusion. In the Carotid artery p. 498: bruit identified as swishing blowing sound and indicates turbulence due to a local vascular cause such as atherosclerotic narrowing. In the abdomen, p. 571, the presence of any vascular sounds must be checked, especially in people with hypertension.
  85. how do you manage an enlarged thyroid?
    • Auscultate for a presence of a bruit
    • Usually not palpable; if they are enlarged usually palpable before swallowing, or too tender to palpate

    • Q: A pt noticed a lump above her adams apple that seems to be getting bigger during
    • the assessment the findings reassures the nurse that it may not be a cancerous
    • thyroid nodule is that the lump is

    A: Mobile and not hard
  86. what does lymphadenopathy feel like?
    • Lymphadenopathy is an enlargement of the lymph nodes (greater than 1 cm) from infection, allergy, or neoplasm. Feels enlarged and tender.
    • Check the area for the source of the problem. For example, those in the upper cervical or submandibular area often relate to inflammation or neoplasm in the head and neck. Follow up on or refer your findings. Enlarged lymph node,
    • particularly when you cannot find the source of the problem, deserves attention.

    • Q: an Enlargement of the lymph nodes greater then 1cm from an infection, allergy, or
    • neoplasm
    • :Lymphadenopathy
  87. what is temporal arteritis?
    Temporal artery is on bone between eye and top of ear, but it feels hardened, tortuous, and tender
  88. Cranial Nerves
    • on old olympus tiny tops a finn and german viewed some hops
    • some say marry money but my brother says boobs matter more
    • I: olfactory- smell
    • II: optic-vision, peripheral, accomodation, literacy
    • III: oculomotor-pupil constriction, 6 cardinal gazes
    • IV:trochlear- eyes down and in
    • V: trigeminal- mouth
    • VI: abducens- lateral movement of eye
    • VII: facial-smile, puff cheecks, show teeth
    • VIII: acoustic/vistibulocochlear- balance, whisper test, rinne/weber test
    • IX:glossopharyngeal- throat, uvula, midline tongue
    • X: vagus-pharynx, larynx, talking, swallowing
    • XI:spinal accessory- shrug shoulders, face against hand
    • XII:hypoglossal- stick tongue out and move side to side
  89. what is normal intraocular pressure?
    • Glaucoma is increased intraocular pressure, which is abnormal
    • Determined by a balance between the amount of aqueous produced and
    • resistance to its outflow at the angle of the anterior chamber
  90. how do you test visual accomodation?
    • Corneal light reflex: Shining a penlight towards eyes in the same place to the other eye; have patient stare straight ahead; See bright white dots
    • Confrontation test: Measures peripheral vision
    • 6 Cardinal signs
  91. what is presbyopia?
    • Glass-like quality decreases lens’ ability to change shape to accommodate for near vision” with aging
    • When patient needs to move card (or whatever is needing to be read), farther away
  92. what are floaters?
    • Common with myopia or after middle age as a result of condensed vitreous fibers
    • Usually not significant but acute onset may occur with retinal detachment
  93. what is the eustachian tube and its function?
    • An opening in the ear that connects the middle ear with the nasopharynx and allows the passage of air
    • Tube is normally closed but it opens with swallowing or yawning
  94. what does the middle ear do?
    • Conducts sound vibrations from outer ear to central hearing apparatus in the inner ear
    • Protects the inner ear by reducing the amplitude of loud sounds
    • Eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (Ex: during altitude changes in an airplane)
  95. what is the importance of air conduction?
    • AC>BC
    • Air conduction is most efficient Pathway: Sounds waves produce vibrations on the tympanic membrane and are carried by the ossicles in the middle ear, it travels up the coils of the cochlea; On the way it vibrated the basilar membrane to signify frequency; The fibers on the basilar membrane (organ of Corti) are bent from vibrations and turns into electric impulses, sending signal to brain; the function of the cortex interprets the meaning of sound and begins appropriate response.
    • Vibrations transmitted directly to inner ear and cranial nerve VIII
  96. what is sensory or neural hearing loss?
    • Signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex
    • Simple increase in amplitude may not enable patient to understand words
    • May be caused by presbycusis, a gradual nerve degeneration that occurs with aging
  97. what is the purpose of ciliated mucous membrane?
    • Nasal cavity lined with blanket of ciliated mucous membranes
    • Filters inhaled air by sweeping out dust and bacteria
    • Bronchi are lined with cilia which sweeps particles upwards where they can be swallowed or expelled
  98. what holds the tongue in the mouth?
    Frenulum is a midline fold of tissue that connects the connect to the floor of the mouth
  99. where are the salivary glands located?
    • Parotid gland (the largest): lies within the cheeks in front of the ear extending from the zygomatic arch down to angle of jaw
    • Submandibular gland (size of walnut): lies beneath the mandible at the angle of the jaw
    • Sublingual (size of almond): under the tongue
  100. what are deep crypts in tonsils?
    • Tonsil Crypts are small pockets that form on the outside of your tonsils.
    • Same color as surrounding mucous membranes, look more gradular
    • These pockets or tonsil crypts collect debris, ike the mucus from nasal drip as well as food particles
  101. what is xerostomia?
    Dry mouth”; side effect of many drugs like antidepressants, antihypertensive, bronchodilators
  102. what part of breast is most important?
    • Tail of Spence = cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.
    • The upper outer quadrant is the site of most breast tumors
  103. what are normal hormonal changes for women?
    • ·
    • Adolescents- at puberty, estrogens stimulate the growth of cells in
    • the reproductive tract and the development of secondary sex characteristics

    • ·
    • Aging female- Ovaries stop producing progesterone and estrogen.
    • During menopause bring dramatic physical changes. Uterus shrinks; vagina becomes shorter, narrower and less elastic.
    • Secretion of estrogen and progesterone decreases causing the breast glandular tissue atrophy
  104. what is gynecomastia?
    • ·
    • Non-inflammatory enlargement of breast tissue in male
    • Usually affect 1 breast and temporary at puberty
    • Occurs with use of anabolic steroids, some medications, and some disease states
    • Common in aging male due to hormonal changes, bilateral and may be tender
    • occurs with hormone stimulations, Cushing’s syndrome, cirrhosis of liver, leukemia occasionally, sometimes with medication
  105. what is rust colored sputum?
    • Rust color = tuberculosis, pneumococcal pneumonia
    • White/clear mucous = colds, bronchitis, viral infections
    • Yellow/green = bacterial infections
    • Pink/frothy = pulmonary edema
  106. evaluation of coughs and different meanings:
    • Continuous throughout day = acute illness (respiratory infection)
    • Afternoon/evening = may reflect exposure to irritants at work
    • Early morning = chronic bronchial inflammation of smokers
    • Night = postnasal drip, sinusitis
    • Chronic bronchitis is characterized by a history of productive cough for 3 months of the year for two years in a row

    • Q: A 40 yr old man has a recent weight loss of 20 lbs and keeps getting the cold and the flu. An additional to nutritional assessment the nurse would want to get what lab
    • A: A total lymphocyte count
  107. how to auscultate breath sounds:
    • Apices → supraclavicular areas down the 6th ribs
    • Side-to-side as moving downward – 1 full respiration each location
    • Don’t place directly over female breast
    • Bronchial = high pitched, loud, inspiration < expiration
    • Bronchovesicular = moderate, inspiration = expiration
    • Vesicular = low, soft, inspiration > expiration
    • Person is sitting, leaning forward slightly. Person should breath through the mouth, a bit deeper than usual, but to stop if he/she begins to feel dizzy. Listen to one full respiration in each location.
    • Use flat diaphragm end piece of stethoscope and hold it firmly on person’s chest wall.
  108. what is short popping sounds that stop after deep breathing and may occur right after waking up from sleep?
    • Atelectatic crackles – sound like fine crackles but do not last and are not pathogenic. Disappear after the first few breaths.
    • Only heard in periphery (axillae and bases), usually dependent portion of the lungs
  109. direction of blood flow through the heart
    • Unoxygenated blood (systemic veins) → Superior Vena Cava/Inferior
    • Vena Cava R. atrium→ R. ventricle→ Tricuspid valve → Pulmonic valve → Lungs by
    • pulmonary arteries→ pulmonary veins (Oxygenated blood) → L. atrium → Mitral
    • valve → L. ventricle → Aortic valve → Systemic circulation
  110. valves of the heart
    • ·
    • 4 valve2 AV (atrioventricular) valves separate atria and ventricles: R =Tricuspid; L = Mitral
    • 2 SL (semilunar) valves separate ventricles and arteries: R =
    • Pulmonic; L=Aortic
  111. electrical sequence of heart
    • SA nodes (pacemaker) →AV node → Bundle of His →R&L bundle branches
    • (Perkinje fibers
  112. sleep, importance
    • Paroxysmal nocturnal dyspnea – awakening from sleep with SOB and
    • needing to be upright to achieve comfort
    • Relates to cardiac problems

    • Q: A 65 yr old pt is awaken from sleep with SOB what would the nurse do?
    • A: A test for PND or Paroxysmal nocturnal dyspnea

    • Q: A 45 yr old man is going for a routine physical during the history the pt states he is having difficult breathing, sleeps fine, and then wakes up and cant catch his breath. The nurses best response would be
    • A: Do you have any history of problems with your heart
  113. risk factors for heart disease?
    • Sedentary lifestyle (physical inactivity)
    • High blood pressure
    • High cholesterol levels
    • Obesity
    • Diabetes
    • Oral contraceptives and postmenopausal hormones
    • Blacks → White→ Mexican-American
    • Q: During a cardiac assessment on an adult pt in the hospital for chest pains the nurse finds the following jugular veins 4 cm above the sternal angle when elevated at 45 degrees, Bp of 98/60, HR 130, angle edema, difficult breathing when suspine, and a S3
    • A: Heart failure
  114. difference between S3 and S4
    • S3
    • (pg. 518) – ventricular filling sound.
    • Occurs early diastole during rapid filling phase
    • Heard best at apex or lower left sternal border; the split S2 at base (heard right after S2)
    • Dull, soft sound, low pitched (lower than S2)
    • May be physiologic (normal) = in children and young adults
    • May be pathologic (abnormal) = in adults usually, S3 gallop, increase compliance of ventricles, (heartfailure), L/R ventricle, L-sided S3 at apex in left lateral position, R-sided S3 at LL sternal border and louder with inspiration
  115. S4:
    • (pg. 519) – ventricular filling sound. Occurs when atria contract late in
    • diastole
    • Heard immediately before S1
    • Very soft, very low pitched
    • Heard best at apex, left lateral position
    • Physiologic = adults >40/50 years old with no evidence of cardiovascular
    • disease
    • Pathologic = atrial gallop or S4 gallop, decreased compliance of ventricle & systolic overload (after load), outflow obstruction of ventricles (aortic stenosis), systemic HTN – L-sided
    • R-sided S4 = less common, heard at LL sternal border and may increase with inspiration, occurs with pulmonary stenosis or pulmonary HTN
  116. Know all about apical pulse, assessing the carotids for bruits
    • PMI (pg. 501)– pulsation created as the left ventricle rotates against the chest wall during systole
    • Location: 4th or 5th intercostals or medial to midclavicular line
    • Size: 1 cm x 2 cm normally
    • “exhale and hold”
    • Short gentle tap, occupies only 1st ½ of systole
    • Not palpable in half of adults especially those who are obese or with thick chest walls
    • Bruits (pg. 498)– blowing swishing sound indicating turbulent blood flow, normally non present (through vascular
    • narrowing)
    • 1) angle of jaw, 2) midcervical area, 3) base of neck
    • Have patient take breath, exhale, and hold while listening

    • Q: When assessing an elderly pt with a carotid artery with cardio
    • vascular disease the nurse would?

    A:Listen with the bell of the stethoscope to listen for bruit

    • Q: While listening to an apical pulse of a 16 yr old pt the nurse notices an irregular rhythm; his rate speeds up on inspiration and slows on expiration. Nurses response
    • A: No further response is needed- Sinus Arrhythmia
  117. what is cardiomyopathy?
    • Any disease that affects heart muscle, diminishing cardiac performance
    • Cardiac enlargement from increased ventricular volume or wall thickness can be due to cardiomyopathy
  118. arteries and where to palpate:
    • Temporal artery (front of ear)
    • Carotid artery (groove between sternomastoid muscle and trachea)
    • Brachial artery (biceps-triceps furrow of upper arm and antecubital fossa in elbow)
    • Radial and ulnar arteries (branched from brachial arteries)
    • Femoral artery (passes under inguinal ligament)
    • Popliteal artery (behind knee)
    • Dorsalis pedis (anterior tibial artery travels down anteriorly towards dorsal side of foot)
    • Posterior tibial artery (travels down behind medial malleolus and in foot forms the planter arteries)

    • Q: During the assessment of a healthy adult where would the nurse expect to palpate the adult
    • A: 5th L intercostals space at the midclavicular line
  119. colon structures and location:
    • RUQ –hepatic flexure of colon, part of ascending and transverse colon
    • LUQ –splenic flexure of colon, part of transverse and descending colon
    • LLQ – part of descending colon & sigmoid colon
  120. how to assess a distended bladder
    • Scratch test = define liver border and distended abdomen
    • Stethoscope over liver, with one fingernail, scratch short strokes over abdomen, start in RLQ up toward liver.
    • When scratching sound becomes magnified, you will have crossed the border over a hollow organ to a solid one
  121. difference between muschle, bone, tendon, ligament:
    • Muscle= 40-50% of body’s weight, produce movements, 3 types (skeletal,smooth, cardiac)
    • Tendon= strong fibrous cord attaches muscles to bones
    • Ligament= fibrous bands running directly from one bone to another bone that strengthen the joint and help prevent movement in undesirable directions
    • Bone= specialized form of connective tissue, hard, rigid, and very dense,support body
  122. osteoarthritis vs. rheumatoid arthritis:
    • Osteoarthritis(pg. 643)
    • -degenerative joint disease
    • -non-inflammatory,localized, progressive disorder involves deterioration of articular
    • cartilages and subchondral bone and formation of new bone (osteophytes) at joint surfaces
    • -asymetric joint involvement commonly affects hands, knees, hips, & lumbar & cervical segments of spine
    • -stiffness,swelling with hard, bony protuberances, pain with motion, & limitation of motion

    • Rheumatoid arthritis ( pg. 643)
    • chronic,systemic inflammatory disease of joints and surrounding connective tissue
    • inflammation of synovial membrane leads to thickening →fibrosis (limiting motion) →bony ankylosis
    • symmetrical & bilateral
    • characterized by heat, redness, swelling, & painful motion of affected joints
    • associated with fatique, weakness, anorexia, weight loss, low grade fever, & lymphadenopathy
  123. Know how to measure edema, muscle strength, deep tendon reflexes
    • Edema:(pg. 542)
    • 1+ = mild pitting, slight indentation, no perceptible swelling of leg
    • 2+ = moderate pitting, indentation subsides quickly
    • 3+ = deep pitting, indent remains for short time, leg looks swollen
    • 4+ = very deep pitting, indent last long time, leg very swollen

    • Muscle strengths (pg. 612)
    • 5 = full ROM against gravity, full resistance, 100%, Normal
    • 4 = full ROM against gravity, some resistance, 75%, Good
    • 3 = full ROM with gravity, 50%, Fair
    • 2 = full ROM with elim. Gravity (passive), 25%, Poor
    • 1 = slight contraction, 10%, Trace
    • 0 = no contraction, 0%, Zero

    • Deep tendon reflexes ( pg. 660, 678)
    • 5 components:

    • 1) Intact sensory nerve (afferent)
    • 2) Functional synapse in cord
    • 3) Intact motor nerve fiber (efferent)
    • 4) Neuromuscular junction
    • 5)Competent muscle

    • 4+ = very brisk, hyperactive with clonus, indicative of disease
    • 3+ = brisker than average, may indicate disease
    • 2+ = average, normal
    • 1+ = diminished, low normal
    • 0 = no response
  124. what is gout?
    • Acute:
    • Metabolic disorder of disturbed purine metabolism (elevated serum uric acid)
    • First in the metatarsophalangeal joint, redness, swelling, heat,extreme tenderness
    • Primarily in men >40 years old
    • Chronic:
    • Extreme swelling and joint deformity
    • Tophi-hard, painless nodule result in 1st toe, sometimes burst with chalky discharge
  125. Parkinsons disease/Parkinsonism:
    • Defect of extrapyramidal tracts in basal ganglia with loss of neurotransmitter dopamine
    • Motor system dysfunction
    • Tremor, rigidity, akinesia
    • Slower monotonous speech and diminutive writing
    • Immobile, flat facial expression, staring
    • Excessive salivation
    • Reduced eye blinking
    • Stooped posture, trunk pitched forward
    • Equilibrium impaired, loses balance easily, passive ROM
  126. genital organs of the male:
    Male -Penis, scrotum (external), testis, epididymis, & vas deferens (internal)

    Glandular structures accessory to genital organs: prostate,seminal vesicles, & bulbourethral glands
  127. female genital organs:
    • External: vulva (pudendum), mon pubis, labia majora, labia minora,frenulum, clitoris, vestibule, urethral meatus,paraurethral gland (Skene’s gland), vaginal orifice, hymen, vestibular (Bartholin’s) glands
    • TEST QUESTION: Can be seen in vestibular exam- Urethral meatus and vaginal orifice.
    • Internal: vagina, (9cm), rugae, cervix (covered in smooth, pink,stratified squamous epithelium), os (covered with columnar epithelium),squamocolumnar junction, anterior/posterior fornix, retouterine pouch (cul-de-sac of Douglas), uterus, fallopian tubes, ovaries
  128. steatorrhea:
    Excessive fat in the stool as in malabsorption of fat
  129. exected symptoms with menopause:
    • Cessation of the menses, around age 45-51.
    • Female hormones decrease rapidly
    • Preceding 1-2 yrs of decline in ovarian function (irregular menses become father apart and lighter flow)
    • Ovaries stop producing progesterone and estrogen (causing dramatic physical changes)
    • Uterus shrinks due to ↓myometrium
    • Ovaries atrophy to 1-2cm and not palpable
    • Ovulation may still occur
    • Sacral ligament relax and musculature weakens, uterus droops (may protrude prolapsed into vagina)
    • Cervix shrinks and paler with thick, glistening epithelium
    • Vagina shorter, narrower, and less elastic
    • Without sexual activity, vagina atrophies half its former length and width
    • Vaginal epithelium atrophies, becomes thinner, drier, and itchy
    • Risk for bleeding and vaginitis (dry irritations and pain with sex– dyspareunia)
    • pH more alkaline
    • Mons pubis smaller
    • labia and clitoris ↓ in size
    • pubic hair thin and sparse
    • Orgasms shorter, resolution more rapid, vaginal secretions andlubrication reduced
  130. What is blood flow disturbance and how do u assess it?
    Q: A 30 yr old women with a history of MVP states she is very tired the nurse palpates a thrill and lift at the 5th intercostals space and midclavicular line and in the same area the nurse hears a blowing, swishing sound at S1. These findings are most consistent with

    A: Mitral Regurgitation