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Combined Sets
MILESTONE+MILESTONE+MILESTONE+MILESTONE+MILESTONE+MILESTONE+MILESTONE+MILESTONE
| Question | Answer |
|---|---|
| Emergency Health Assessment | Life threatening/unstable condition. Remember the ABCDE ---- A(Airway), B(Breathing), C(Circulation), D(Disability), E(Exposure) |
| Comprehensive Assessment | Complete health history, physical assessment, health perception, meds, strengths, risks, functional ability, coping methods, support systems |
| Focused Assessment | Occurs in all settings. Usually, 1 or 2 body systems. Smaller in scope, but more in depth in assessed area |
| Primary Health Prevention | Weight loss, diet, exercise, smoking cessation, reduced alcohol, avoid drug use, farm safety, seat belts, car seats, immunizations, water treatment, safe sex, effective parenting |
| Secondary Health Prevention | Screenings such as BP, glaucoma, HIV, skin cancer, pap smears, mammograms, testicular exams, family counseling |
| Tertiary Health Prevention | Medications, medical therapy, surgeries, rehab, PT, OT, Job training |
| Primary Health Preventions Focus on | Teachings |
| Secondary Health Preventions Focus on | Screening |
| Tertiary Health Preventions Focus on | Curing/Treating existing Disease, to reach max level of functioning |
| Source | Encoder |
| Receiver | Decoder |
| Channel | Visual (signals observations, and perception), Auditory (spoken words or cues), Kinesthetic (touch) |
| Message | Actual Communication |
| Noise | Distorts quality |
| Feedback | Understanding |
| Verbal Communication | Spoken or written words |
| Nonverbal Communication | Body lingual and expressions |
| Pre-interaction Phase | Before meeting with patient, you check EMR |
| Beginning Phase | Introducing, ask how they want to be addressed explain procedure |
| Working Phase | Collecting data subjectively and objectively. Using open-ended (elaborative) or closed ended (yes/no) questions |
| Closing Phase | End by summarizing and state 2-3 patterns or problems. Ask if they would like to share anything else |
| Importance of Documentation | Legal Document, Financial Reimbursement, Medical History, and Communication among caregivers |
| Pregnancy Nutritional Requirements | Additional 300-500 cal/day (emphasis on protein) vitamins and minerals |
| Adolescents Nutritional Requirements | Increased calories, proteins, calcium, iron |
| Infants and young children Nutritional Requirements | Amino acids from protein are most important due to rapid growth |
| Older Adults Nutritional Requirements | Decreased thirst and taste diminished puts them at risk for diabetes, dehydration, and malnutrition |
| Malnutrition | Malnutrition and dehydration are common in elderly and in long-term care facilities. Increased risks of osteoarthritis, osteoporosis, dementia, and obesity |
| Abuse | Always be in a private, safe place, do not ask if they want to press charges, simply ask directly |
| Leininger Cultural Care Diversity and Universality Theory/Model | Cultural values and beliefs of religion, personal philosophy of life, spiritual beliefs, educational, and economic backgrounds, relationships with family and friends, views of technology, politics, and legal status |
| Purnell’s Model of Transcultural Health | Age, Gender, Nationality, Ethnicity, Values, Religious Beliefs, Morals, Job, Socioeconomic status, reason for migration, and beliefs about health |
| Campinha-Bacote’s model of cultural competence | Cultural awareness, knowledge, skill, encounters, and desire |
| Giger & Davidhizar’s Model of Transcultural Nursing | Communication, space, social, time, environment, biology |
| Which Cultural Theory focuses on providing all-inclusive pictures of the patients culture based on health care needs | Leininger’s Cultural Care Diversity and Universality Theory/Model |
| Which Cultural Theory focuses on the patient’s own personal development | Purnell’s Model of Transcultural Health |
| Admission Hospital Assessment | comprehensive, more detailed and more complete than other assessments. Focuses on evaluation progress towards goals |
| Shift Hospital Assessment | performed at the beginning of work, and includes abbreviated examination with emphasis on risk areas, such as auscultation of lungs, abdomen, and assessment of circulation and level of consciousness |
| Focused Hospital Assessment | concentrates on assessing for anticipated problems that can result from hospitalization, such as pneumonia, skin breakdowns, falls, infections, and those specific to patient’s problems and prior to transfers. |
| General Survey First impression | Overall appearance, hygiene and dress, odors, etc? |
| General Survey Skin | Dry, moist, texture, temp, color |
| General Survey Speech | Can patient participate in conversation |
| General Survey Body Structure and development | Muscle tone and strength, malformations, clubbing |
| General Survey Consciousness | Awake? Alert? Responds to name? |
| General Survey Mobility, posture, gait, ROM | Can they move extremeties completely? Enlarged joints? |
| General Survey Facial Expression | Do they appear healthy or ill? |
| Mnemonic to remember for PAIN | O P Q R S T à O (onset) P (provocative/palliative) Q(quality) R (region/radiation) S (Severity) T (Timing) |
| Behavioral Patterns for Pain in the Neuro System | Agitation, restless, stillness, irritability, fear, anxiety, fatigue |
| Behavioral Patterns for pain in the Cardio System | Tachycardia, increased BP and O2 Demand, increased cardiac output |
| Behavioral Patterns for Pain in the Pulmonary System | Hyperventilation with anxiety, hypoventilation with pain, shallow respirations, hypoxia, depressed cough, atelectasis |
| Behavioral Patterns for Pain in the GI System | Nausea, vomiting, decreased bowel sounds, stress, ulcer |
| Behavioral Patterns for Pain in the GU System | Reduced urine output or retention |
| Behavioral Patterns for Pain in the M/S System | Muscle tension, spasms, joint stiffness, immobility |
| Behavioral Patterns for Pain in the Integumentary System | Pallor, diaphoresis |
| Behavioral Patterns for pain in Metabolics | Catabolism, glucose, lactate, ketones, impaired immune function, delayed wound healing |
| Emotional Pain Indicators | Depression, excessive sleeping, anxiety, fear, impaired individual or family coping |
| Social Pain Indicators | Isolation, impaired role performance, impaired home maintenance, financial burdens |
| Vocalization Pain Indicators | Moaning, groaning, grunting, sighing, gasping, crying, screaming |
| Verbalization Pain Indicators | States pain, praying, counting, swearing, repeated phrases |
| Facial Expression Pain Indicators | Clenching teeth, grimacing, shutting lips tightly, starring, facial mask, wrinkling forehead, tearing |
| Body Actions Pain Indicators | Thrashing, pounding, biting, rocking, rubbing, stretching, shrugging, rotating body part, shifting weight, massaging, immobilizing, guarding, bracing, applying pressure, heat, or cold, assuming special positions, posture, crossing legs |
| Normal HR & BP for Newborns | 70-190 & 73/55 |
| Normal HR & BP for Infants | 80-160 & 85/37 |
| Normal HR & BP for Toddlers | 80-130 & 89/46 |
| Normal HR & BP for Children | 70-115 & 95/57 |
| Normal HR & BP for Preteens | 65-110 & 102/61 |
| Normal HR & BP for Teens | 55-105 & 112/64 |
| Normal HR & BP for Adults | 60-100 & 120/80 |
| What factors contribute to BP | Cardiac output, peripheral vascular resistance, circulating blood volume, viscosity, and elasticity of the vessel walls |
| What factors can cause a false low BP reading | Noisy environment, large cuff, improper earpiece placement of stethoscope, not over brachial artery, hearing deficit, deflating too quickly, or too slowly, failing to palpate radial artery for estimated SBP, arm position above heart level |
| What factors can cause a false high BP reading | Assessing right after exercise, when anxious or angry, cuff too small, cuff too loose, reinflation of cuff during auscultation, arm below heart level, patient supporting arm, legs crossed. |
| Hypotension is when | Systolic is less than 90 |
| Normal BP | Systolic is less than 120, AND, diastolic is less than 80 |
| Elevated BP is | Systolic 120-129, AND diastolic is less than 80 |
| Stage 1 Hypertension is when | Systolic 130-149, OR diastolic 80-89 |
| Stage 2 Hypertension is when | Systolic 140 or higher, OR diastolic is AT LEAST 90 |
| Hypertensive Crisis is when | Systolic is higher than 180, OR diastolic is higher than 120 |
| Superficial Pain Sensation | Breaking tongue blade or cotton swab so end is sharp, having patient close eyes, lightly touch the patient’s skin and ask the patient to state where they feel sensation |
| Hyperalgesia | increased pain sensation |
| Hypoalgesia | reduced pain sensation |
| Analgesia | absent pain sensation |
| Inspect external eyes to evaluate | Symmetry, redness, deformities |
| We test distance vision to evaluate | Ability to see far, and drive |
| We test near vision to evaluate | Ability to read |
| We test cardinal fields of gaze to evaluate | Movement of the eye in several planes of movement |
| We inspect and palpate lacrimal apparatus and conjunctiva to evaluate | Swelling, tenderness |
| We test pupillary reflex to evaluate | Pupil response to direct and consensual light |
| We test for static confrontation to evaluate | Differences in visual field from side-to-side and inferior and superior |
| We test for kinetic confrontation to evaluate | Peripheral vision |
| We test corneal light reflex to evaluate | Strabismus |
| We perform cover tests to evaluate | Ocular deviation |
| We inspect cornea and lens to evaluate | Glaucoma and cataracts |
| We inspect posterior eye to evaluate | Disc, vessels, macula, and periphery for damage with nerves or circulation |
| The Snellen Test | Assesses distance vision from 20 ft away, covering one eye at a time, glasses and contacts (except reading glasses) stay on |
| The Allen Test | Assess distance vision from 20 ft away, covering one eye at a time |
| Jager Test | Assess near vision, pocket screener, holds card about 14 inches from eyes, covers one eye, reads smallest letters possible |
| Static Confrontation | Stand approx. 2-3 feet apart (arms length) eyes at same level. Have patient cover left eye with hand, you close right eye, keep vision directly on each others eyes, present fingers in peripheral in each of 5 quadrants and have patient report the number. |
| Assessment of Extraocular Muscle Movements is assessment through | Cover test, cardinal fields of gaze, and corneal light reflex |
| Order of lymph node assessment | Preauricular, posterior auricular, occipital, submental, submandibular, tonsillar, superficial cervical, deep cervical, posterior cervical, supraclavicular |
| Enlarged Anterior Cervical Lymph Nodes indicate | Pharyngitis |
| Enlarged Posterior Cervical Lymph Nodes indicate | Mononucleosis |
| Enlarged Posterior Auricular Lymph Nodes indicate | Otitis Media |
| Enlarged Supraclavicular Lymph Nodes indicate | Possible metastatic cancer |
| Hard, rubbery, irregular, fixed, and nontender lymph nodes are possibly signs of | Lymphoma |
| Vesicular Breath Sounds | Soft, low-pitched, and found over fine airways near site of air exchange (lung periphery) Whispering undertones, heard greater in inspiration |
| Bronchovesicular Breath Sounds | Found Centrally, over major bronchi, and have fewer alveoli, Intermediate sounds, heard equally in inspiration and expiration, heard anteriorly between 1st and 2nd ICS |
| Bronchial Breath Sounds | Loud, high-pitched, and found over trachea and larynx, Considered coarse or tubular, heard more expiration |
| Adventitious breath sounds are | Crackles, wheezes, rhonchi, pleural friction rub, and stridor |
| Fine Crackles | High-pitched, soft, brief sounds that can be simulated by rolling a strand of hear near stethoscope. Often heard in Fibrosis, and heart failure or COPD and asthma |
| Coarse Crackles | Moist sounded, longer sounds, similar to Velcro separation, often seen is respiratory fibrosis, respiratory edema, and COPD |
| Wheezing | Musical sounds, often seen is asthma, bronchitis, and emphysema |
| Rhonchi | Snoring or gurgling sound that may clear with coughing, often seen in pneumonia |
| Pleural friction rub | Coarse and creaking sound similar to a squeaky door. Often seen in pleuritis. |
| Stridor | Crowing or honking sounds louder in the upper airway. Often heard in croup, epiglottitis, partially obstructed airway, can be an emergency situation |
| Bronchophony | Patient says ninety-nine, and it should sound muffled. |
| Egophony | Patient says e and it should sound like e, not a |
| Whispered pectoriloquy | The patient says ninety-nine quietly and it should not be heard |
| Apex | Bottom of heart |
| Base | Top of heart |
| PMI | Where apical pulse is found, between 4-5th ICS in mitral area |
| S1 | Lub sound, heard in the beginning of ventricular systole |
| S2 | Dub sound heard at the end of systole and beginning of diastole |
| Tricuspid Valve | Separates the right atrium and right ventrical |
| Mitral Valve | Separates the left atrium and left ventricle |
| Pulmonic Valve | Lies between right ventricle and pulmonary artery and fills the lungs |
| The Aortic Valve | Lies between left ventricle and left aorta, and fills the blood flowing into the body |
| MI | Chest pain, discomfort, fatigue, SOB, lasting more than 20 minutes. Often accompanied by nausea and diaphoresis, often alleviated with thrombolytic meds, or angioplasty if necessary |
| Stable Angina | Discomfort that lasts less than 20 minutes, often brought on by cold, fatigue, physical exertion, and alleviated with nitroglycerin and rest |
| Unstable angina | Discomfort lasting less than 20 minutes, occurs at rest, and often alleviated with nitroglycerin |
| Inspect the abdomen for | Shape, contour, and movement, distension, pulsations, |
| Pulsations of the aorta may be increased and lateralized in an | Abdominal Aortic Aneurysm |
| The collection of fluid in the abdomen are | Ascites |
| Normoactive bowel sounds | 5-30 sounds per minute |
| Hypoactive bowel sounds | Less than 5 sounds per minute |
| Hyperactive bowel sounds | More than 30 sounds per minute |
| Flexion | Decreases the angle between bones or brings bones together |
| Extension | Increases the angle to a straight line or zero degrees |
| Hyperextension | Extension beyond neutral position |
| Abduction | Movement of a part away from the center of the body |
| Adduction | Movement of a part toward the center of the body |
| Rotation | Turning of the joint around a longitudinal axis |
| Internal Rotation | Rotating an extremity laterally along its axis |
| Pronation | Turning the forearm so the palm is down |
| Supination | Turning the forearm so palm is up |
| Circumduction | Circular motion that combines flexion, extension, abduction, and adduction |
| Protraction | Moving a body part backward and parallel to the ground |
| Elevation | Moving a body part upward |
| Depression | Moving a body part downward |
| Opposition | Moving the thumb to touch the little finger |
| Inversion | Turning the sole of the foot inward |
| Eversion | Turning the sole of the foot outward |
| Dorsiflexion | Bending ankle so toes move toward the head |
| Plantar Flexion | Moving foot so toes move away from the head |
| Olfactory Cranial Nerve (I) | Sensory, smell and smell interpretation, including peristalsis, salivation, and sexual stimulation |
| Optic Cranial Nerve (II) | Sensory, vision, including visual acuity and peripheral vision |
| Oculomotor Cranial Nerve (III) | Motor, Extraocular Movements of eye including upward, medial, downward, up and in, eyelid raising, and pupil constriction |
| Trochlear Cranial Nerve (IV) | Motor, Extraocular Movements of eye including down and in |
| Trigeminal Cranial Nerve (V) | Sensory&Motor, ophthalmic for sensation to cornea, conjunctiva, nasal mucosa, forehead & nose. Maxillary, sensation to skin of cheek & nose, lower eyelid, upper jaw, teeth & oral mucosa. Mandibular, sensation to the lower jaw & motor function for chewing |
| Abducens Cranial Nerve (VI) | Motor, Extraocular Movements of the eye including later |
| Facial Cranial Nerve (VII) | Sensory & Motor, taste and sensation for anterior two-thirds of the tongue and soft palate. Serves as primary motor nerve for facial expression |
| Acoustic Cranial Nerve (VIII) | Sensory, hearing and equilibrium |
| Glossopharyngeal Cranial Nerve (IX) | Sensory & Motor, pharyngeal elevation for swallowing and speech. Parotid gland secretion, general sensory (pain, touch, temp) function |
| Vagus Cranial Nerve (X) | Sensory & Motor, Provides most parasympathetic innervation to large region. Effects include digestion, defecation, slowed HR, and reduced contraction strength |
| Spinal Accessory Cranial Nerve (XI) | Motor, swallowing and speaking, innervates the muscles that turn the head and elevates the shoulders (shoulder shrug) |
| Hypoglossal Cranial Nerve (XII) | Motor, tongue movement |
| Which cranial nerves are located in the Cerebral Hemisphere | Olfactory (I), and Optic (II) |
| Which cranial nerves are located in the Midbrain | Oculomotor (III), and Trochlear (IV) |
| Which cranial nerves are located in the Pons | Trigeminal (V), Abducens (VI), Facial (VII), and Acoustic (VIII) |
| Which cranial nerves are located in the Medulla | Glossopharyngeal (IX), Vagus (X), Hypoglossal (XII), Spinal Accessory (XI) |
| The frontal lobe is responsible for | Complex cognition (orientation, memory, insight, judgment, arithmetic, and abstraction, language (verbal and written), and voluntary motor function |
| The occipital lobe is responsible for | Primary visual area, visual associative areas that interpret and integrate stimuli |
| The parietal lobe is responsible for | Recognizes the size, shape, and texture of objects, as well as interprets touch, pressure, and pain |
| The temporal lobe is responsible for | Registers auditory input and is responsible for hearing, speech, behavior, and memory |
| Broca Area of the brain | Regulates verbal expression and writing ability |
| Wernicke Area of the brain | Integrates understanding of spoken and written words |
| The reflex arc order | Receptor-Sensing Organ à Afferent Sensory Neuron à Efferent Motor Neuron à Effector Motor Organ |
| Level of Consciousness | Alertness |
| Assess Attention | Cognitive functions and processing |
| Assess Communication/Speech | Aphasia or dysarthria |
| Inspect Pupillary Responses | CNII function and ICP |
| Check for abnormal posturing | Severity of deficits |
| Test function of CNs III-VII | Basic Evaluation |
| Evaluate muscle tone and strength | Upper & lower motor function |
| Check gait and balance | Basic cerebellar function |
| Evaluate complex cognitive function | Orientation, cognition, memory |
| Assess function of CNs I-XII thoroughly | Comprehensive evaluation |
| Assess rapidly alternating movements, finger-to-nose and heel-to-shin test | Advanced cerebellar function |
| Temp sensation, vibration sensation, motion & position sense, stereognosis, graphesthesia, two-point discrimination, and extinction | Advanced sensory function |
| Assess deep tendon and superficial reflexes | Intact reflex arc |
| The nursing outcome statement is | Specific, measurable, attainable, realistic, and time |
| A placebo is a | pharmacologically inactive substance that is often used in trials. The patient should not be aware |
| A living will | Provides specific instructions about the health care that should or should not be provided in particular situations |
| Durable Power of Attorney | An agent the person trusts to make decisions in the event of that the person cannot |
| Restraints | Can increase the risk of injury and are used to protect the patient and others from harm |
| Droplet precautions | Use private room, door can stay open, wear PPE upon entry and for all interactions that involve contact or contaminated items. Keep visitors 3 feet away with a mask. Have the patient wear a surgical mask when transferring out of the room |
| Pressure ulcer infection | swelling, pain, exudate, purulent, WBC |
| Serous Drainage | Primarily clear portion of blood and membranes. Is clear and watery |
| Sanguineous Drainage | Large number of RBC and looks like blood |
| Bright Red | Fresh bleeding |
| Dark Red | Old bleeding |
| Purulent Drainage | WBC, liquefied dead tissue and debris, and both dead and live bacteria are present. Often thick with a musty or foul odor, varies in color |
| Wound irrigation fluid | Normal Saline Solution 0.9% sodium chloride |
| Nasopharyngeal Suction Assessment | Lung sounds, the need for suctioning. Note the amount, color, consistency of secretions. Document lung sounds before, during, and after suctioning, assessing pH, RR, effort and rhythm of breathing, and O2 before, during, and after suctioning |
| Eye drop administration | 1 minute apart if same med, and five minutes apart if different med |
| Enema Prep | Ensure client understands what and why enemas are used and how they are performed. provide privacy, do not discount fears, remember they have a right to refuse, do not threaten the patient |
| Sleep assessment includes | Patterns, hours of sleep per night, quality, naps, energy level, relaxation techniques, bedtime rituals, sleep environment, pharmacological aids, the nature, severity and symptoms of disturbance, and interventions attempted |
| DNR | Do not resuscitate. Expressed wishes that there will be no attempts to save the persons life if they stop breathing or their heart stops |
| Smoking | the nicotine can have a stimulating effect and make it difficult to fall asleep |
| Active ROM | involves moving the client's joints through their full range of motion without help |
| Passive ROM | includes the nurse assisting the patient with ROM |
| Kubler Ross five stages of death | Denial and isolation, anger, bargaining, depression, and acceptance |
| Somatic pain | originates in ligaments, tendons, nerves, blood vessels, and bones |
| orthostatic hypotension | is a drop of 10 or more in BP upon moving positions |
| hypertonic enemas | expend osmotic pressure to draw fluid out of interstitial spaces into the colon and rectum to distend the bowel which causing an increase in peristalsis resulting in a bowel movement |
| Which type of enema are used for patients who cannot endure a large volume enema | Hypertonic |
| Nasogastric tube attached to suction should | have intake and output recorded at the end of each shift and every 24 hours. Suction should never go higher than 120, monitor tube patency every hour, oral hygiene every 2 hours |
| Sims position | Lying on abdomen with one legged pulled up. Often used for enemas |
| Prone position | Lying flat on abdomen |
| Antibiotics have the highest change of causing | anaphylaxis reactions and superinfections |
| Which medications may increase the clients risk of falls | Antidepressants, Antihypertensives, Antidysrhythmics |
| What are therapeutic responses of a diuretic | Weight loss, increased urinary output, improved heart function, and decreased BP |
| Glucocorticoid steroids can cause | hyponatremia, hypokalemia, hypocalcemia |
| When administering a corticosteroid metered dose inhaler | have the patient upright, wait one minute between puffs, shake before use, use extender, and rinse mouth after use |
| Antitussives | Reduce cough |
| What labs should be monitored in Acetaminophen use | liver function tests |
| When mixing corticosteroids and diuretics | the patient has a higher risk of hypokalemia |
| Which medication is often used to treat infections when they have an allergy to penicillin | tetracycline |
| side effects of tetracyclines | interferes with tooth enamel and can cause discoloration of teeth in the young or if taken during pregnancy |
| What should be monitored prior to the administration of isoniazid | Liver enzymes |
| What is the priority assessment when treating a patient with morphine | Respiratory status |
| What should be done before administering antibiotics | culture specimen |
| Which medication is safe for a patient with high risk of bleeding | acetaminophen |
| ACE inhibitor suffix | Pril |
| What is a common side of effect of ACE inhibitors | Cough |
| What is the most serious side effect of ACE inhibitors | angioedema |
| What foods should be avoided in TB med treatments | Chocolate, aged cheese, beer, fish |
| hyperglycemia may occur in | corticosteroid use |
| what should we avoid when taking calcium channel blockers | grapefruit juice |
| what should we avoid when taking ACE inhibitors | potassium |
| furosemide is | a strong, potent loop diuretic |
| Levothyroxine | thyroid hormone |
| what drug may cause uncontrollable polyuria | a diuretic like furosemide |
| Histamine H2 | promote gastric secretions |
| calcium channel blockers | block sodium from entering muscle cells of the heart and arterioles to relax and dilate arteries and slow SA/AV node conduction |
| Levethyroxine | has a long half-life of about 7 days and can cause reversible hair loss |
| We assess the pedal pulse | to assess the circulation of extremities and evaluate venous return, DVT, and in the use of compression stockings |
| When assessing the geriatric pulse | they have a decreased elasticity of arteries, which increases peripheral resistance and increases BP |
| Reduced Level of consciousness evaluation | spontaneous, normal voice, loud voice, gently shake, and then apply nail bed pressure to elicit the pain response |
| Orientation is assessing | the patient for alertness, and orientation to person, place and time |
| What is the first thing a patient generally loses | time, then place, and finally person |
| When documenting seizures | document in the frequency chart, the amount, time began, and ending time. Document any factors and symptoms the patient may feel prior to seizure activity |
| To monitor for orthostatic hypotension | we have the patient change positions from sitting, lying, and standing waiting 2 minutes in between. 10-15 drop may indicate orthostatic hypotension |
| pupillary responses | Assess the shape and size, and if they dilate consensually in dark and constrict the same in light. |
| The eyes should be | black, round, equal, with 2-6 mm and constrict directly and consensually |
| PERRLA | Pupils equal, round, reactive to light, and accomodation |
| Bronchial breath sounds | loud high-pitched, and found over the trachea and larynx. Tubular or coarse. heard more in expiration |
| Wheezing | Musical |
| Crackles | Velcro |
| Stridor | Honking seal |
| Pleural Friction Rub | Door creeking |
| Rhonchi | Rattle, cleared with cough |
| Barrel Chest | hyperinflated lungs seen in patients with COPD, emphysema 1:1 indicates barrel chest. 1:2 normal |
| Auscultate the carotid arteries with | the bell |
| Palpate carotid arteries | one at a time |
| when assessing the legs | the most important part is comparing them for edema, pulses, and temp |
| Menopause | 12 consecutive months without menses. Estrogen levels decrease, uterus becomes smaller, ovaries shrink, and epithelium atrophies |
| Menopause increases the risk | of infections, UTIs, diminished libido, and cancers of the endometrial, vaginal, and vulvar |
| Menorrhagia | Heavy or prolonged menstrual bleeding. Can be caused by hormone problems, uterus issues, or other health conditions |
| Perianal assessment | for pain, redness, and swelling in one area of the perineum that quickly progresses and worsens in hours. indicated an infection called Gangrene which is a necrotizing soft-tissue infection |
| Adduction | movement of a part toward the center of the body |
| Atrophy | Wasting or shrinking of muscles which can happen while waring a cast. Assess extremities for symmetry, tone, strength, and note the shape, size, alignment, and deformities |
| Carpal Tunnel | Can cause prickly or tingly sensations, with pain. Due to nerve damage from repetitive movements |
| Peripheral Paresthesia | abnormal prickly or tingly sensations most commonly in the hands, arms, legs, and feet. Happens in many antihypertensive meds |
| Sensory history | those who suffered stoked will have sensory defects on the opposite side of the body |
| Normal Hemoglobin level | 12-18 |
| Normal Hematocrit level | 40-50% |
| Normal Serum Albumin Level | 3.5-5.5 |
| Normal Prealbumin Level | 23-43 |
| Normal Transferrin level | 240-480 |
| Normal Blood Urea Nitrogen (BUN) level | 17-18 |
| Normal Creatinine Level | 0.4-1.5 |
| Decreased hemoglobin, and decreased hematocrit indicates | anemia |
| Increased hematocrit or increased creatinine indicates | dehydration |
| Decreased serum albumin indicates | malnutrition, prolonged protein depletion, malabsorption |
| Decreased pre albumin indicates | protein depletion, malnutrition |
| Decreased transferrin indicates | anemia, protein deficiency |
| Decreased Blood Urea Nitrogen (BUN) indicates | Malnutrition, overhydration |
| Decreased Creatinine indicates | reduction in total muscle mass, severe malnutrition |
| Increased Blood Urea Nitrogen (BUN) Indicates | Starvation, high protein intake, severe dehydration |
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