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Combined Sets
EXAM 3 HEALTH ASSESS+EXAM 3 HEALTH ASSESS+EXAM 4 HEALTH ASSESS+EXAM 4 HEALTH ASS
| Column 1 | Column 2 |
|---|---|
| Apex | Bottom of the heart about the 5th ICS, left of midsternal line |
| Base | Top of the heart, about 2nd ICS spanning from left sternal border to the right |
| Point of Maximal Impulse (PMI) | Area where apical pulsation can be seen or palpated |
| The right side of the heart is more | Anterior |
| The left side of the heart is more | Posterior |
| Carotid Arteries | Transport blood from heart to head |
| Septum | Divides the heart in half |
| Left side of the heart circulates blood | To the entire body against high pressure |
| Right side of the heart circulates blood | To the lower pressure pulmonary systems |
| Atria | Upper chambers of the heart and collect and pump blood into ventricles |
| Ventricles | Pump blood out of the lungs and body |
| Atrioventricular (AV) valves | Separate the atria and ventricles |
| The AV nodes are open during | Ventricular filling (diastole) |
| The AV nodes are closed during | Ventricular Contraction (Systole) to prevent regurgitation or backflow of blood |
| The Tricuspid Valve | Separates the right atrium and left ventricle |
| The Mitral (bicuspid) Valve | Separates the left atrium and left ventrice |
| The two semilunar valves separate the ventricle from | Great vessels |
| Semilunar Valves open during | Ventricular contraction (Systole) to allow blood to flow from ventricles to great vessels |
| The pulmonary valve lies | Between Right ventricle and pulmonary artery |
| The aortic valve lies | Between the left ventricle and aorta |
| Venous Great Vessels are | Jugular veins, superior vena cava, inferior vena cava, and pulmonary artery |
| Superior vena cava | Return oxygenated blood from body to right side of the heart |
| Pulmonary Arteries | Carry venous blood from the right side of the heart to the lungs to be oxygenated |
| Arterial Great Vessels are | The aorta, and pulmonary veins |
| The pulmonary Veins | Carry oxygenated blood from the lungs to the left side of the heart |
| The aorta | Carries blood to the body |
| The venous System consists of | Veins, venules, and connecting veins called perforators, which collect unoxygenated blood from the body and return it to the heart |
| Veins | Thin-walled |
| The venous system is a | Low pressure system |
| The veins of the upper extremities (upper torso, head, and neck) drain into | Superior vena cava and then to the right atrium |
| Regulation of blood flow in the venous system | A pressure gradient created by respiration, skeletal muscle contraction, and intraluminal valves regulates blood flow in the venous system |
| During inspiration the | Diaphragm drops and abdominal pressure increases |
| During Expiration the | Abdominal pressure decreases, creating a suction effect that promotes venous return |
| The lymphatic system consists of | lymph nodes, and lymphatic vessels, spleen, tonsils, and thymus |
| The purpose of the lymphatic system is to | Maintain fluid and protein balance, and functions with the immune system to fight infection |
| The lymphatic vessels carry | Lymph in the tissues back to the bloodstream, and often run parallel to arteries and veins |
| The thoracic ducts at the junctions of subclavian and internal veins | Return the lymph fluid back to circulation |
| Which lymph nodes are assessable for palpation? | Only superficial lymph nodes |
| Lymphatic flow in the arms drain to | Epitrochlear axillary and infraclavicular nodes |
| The lower extremeties lymph drains to | Inguinal nodes |
| Murmurs can result from | Vibration of tissue or excessive flow (as in pregnancy) |
| Assessment of Lower Extremities | Assess symmetry, ROM, Color, Hair, Nails |
| Joints | Where two bones come together |
| Fibrous (Synarthrotic) Joint | Joints are immovable. Such as cranium |
| Cartilaginous (Amphiarthrotic) Joints | Joints are lightly moveable, such as the costal cartilage between sternum and ribs and symphysis pubis |
| Synovial (diarthrotic) Joints | Joints that are the most common type, freely movable and are names for their major type of movement |
| Ball and Socket Joint | The hip and Shoulder |
| Hinge Joint | Elbow & Knee |
| Pivot Joint | Atlas and Axis |
| Condyloid Joint | Wrist |
| Saddle Joint | Thumb |
| Gliding Joint | Intravertebral |
| Flexion | Decreases angle between bones or brings bones together |
| Dorsiflexion | Bending of ankle so toes move toward the head |
| Plantar Flexion | Moving the foot so the toes move away from the head |
| Extension | Increases the angle to a straight line or zero degrees |
| Hyperextension | Beyond neutral position |
| Abduction | Movement of a part away from center of body |
| Adduction | Movement of a part toward the center of the body |
| Rotation | Turning of a the joint around longitudinal axis |
| Internal rotation | Rotating and extremity medially along its axis |
| External Rotation | Rotating and extremity laterally along its axis |
| Pronation | Turning the forearm so the palm is down |
| Supination | Turning the forearm so the palm is up |
| Circumduction | Circular motion that combines flexion, extension, abduction, and adduction |
| Inversion | Turning the sole of the foot inward |
| Eversion | Turning the sole of the foot outward |
| Protraction | Moving the body part forward and parallel to the ground |
| Retraction | Moving the body part backward and parallel to the ground |
| Elevation | Moving body part upward |
| Depression | Moving body part downward |
| Opposition | Moving thumb to touch the little finger |
| Abnormal weakness, tingling, and numbness indicates | Pressure on nerves |
| Abnormal bone pain that is increased with movement indicates | Fractures |
| Abnormal Generalized systemic swelling indicates | Renal Failure |
| Abnormal Ataxia, uncoordinated movements, or loss of balance can indicate | Cerebellar Disorders such as Parkinson's, MS, Strokes, Brain Tumors, Inner Ear Problems, or Some Meds |
| Atony | Lack of normal muscle strength or tone |
| Hypotonicity | Diminished tone of skeletal muscles |
| Spasticity | Hypertonic, so muscles are stiff and movements awkward |
| Spasm | Sudden, violent, involuntary contract of muscle |
| Fasciculation | Involuntary twitching of muscle fibers |
| Tremors | Involuntary Contraction of muscles |
| Normal ROM for shoulder forward Flexion | 180 degrees |
| Normal ROM for Shoulder Abduction | 180 degrees |
| Normal ROM for shoulder Adduction | 50 degrees |
| Normal ROM for shoulder Internal & External Rotation | 90 degrees |
| To test muscle strength | Have patient shrug both shoulders, flex forward and upward, and abduct against resistance. |
| Shrugging the shoulders tests muscle strength and | Cranial Nerve XI (Spinal Accessory Nerve) |
| Normal ROM for Cervical Spine Flexion | 45 Degrees |
| Normal ROM for Cervical Spine Hyperextension | 55 Degrees |
| Normal ROM for Cervical Spine Lateral Flexion | 40 Degrees |
| Normal ROM for Cervical Spine Rotation | 70 Degrees |
| The peripheral nervous system consists of | the cranial, spinal, and peripheral |
| The peripheral consists of all the nerve fibers outside the brain and spinal cord, the | 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all of their branches |
| The peripheral system carries input to the CNS via | Sensory afferent fibers |
| The peripheral System delivers output from the CNS via | Motor Efferent Fibers |
| The central nervous system consists of | the brain and spinal cord and is broken up and classified according to the function as voluntary or involuntary |
| The Somatic Nervous System | Voluntary movements. Peripheral nerve fibers connect to the CNS to muscles and skin facilitate deliberate and voluntary motor actions in response to stimuli |
| The autonomic system | Involuntary movements. Peripheral fibers connect to the CNS to organs, INCLUDING THE HEART AND KIDNEYS, and smooth muscles and glands |
| The cerebrum | Largest part of the brain, composed of 2 hemispheres, and divided into four lobes names after the cranial bones they overlay which make up the cerebral cortex |
| The cerebral cortex consists of | The frontal, Parietal, Temporal, and Occipital Lobes |
| The main function of the cerebrum is | to control the voluntary muscle movements of the body |
| Frontal lobe | Contains the Prefrontal, Premotor, Motor, and Broca's Area. Responsible for memory, judgement, arithmetic, and abstract thinking |
| Broca Area (Left Cortex) | Speech (expression) |
| Parietal Lobe | Contains the Somatosensory Area for sensation and interpretation of speech |
| Occipital Lobe | Contains Visual Cortex. Responsible for vision. |
| Temporal Lobe | Contains Auditory Cortex, Olfactory Cortex, and Wernicke Area. Responsible for hearing, smell, and comprehension of speech and memory |
| Wernicke Area (Left Cortex) | Comprehension of speech, memory |
| Extrapyramidal System | Controls and coordinates skeletal muscle activity such as arm swinging and walking |
| Medulla Oblongata | Control and Coordination centers for respiration and cardiovascular activity. Swallow Reflex center, vomiting reflex, cough reflex. Nuclei of five cranial nerves |
| Hypothalamus | autonomic nervous system. Links with endocrine system. Control of body temp, fluid balance, centers for thirst, hunger, controls vital functions of temp, HR, BP, sleep, anterior & Posterior pituitary, and emotions. IT MAINTAINS OVERALL AUTONOMIC CONTROL |
| Thalamus | sensory sorting and relay center. Directly above the brainstem. Is the major relay station and gatekeep for both motor and sensory stimuli to the cerebral cortex. |
| Basal Nuclei/Basal Ganglia | Coordination and control of body movement. Modulate autonomic movements, receiving input from cerebral cortex and sending output to the brainstem and thalamus to facilitate smooth motor function. |
| Reticular Activating System | Arousal or awareness |
| Limbic System | Emotional responses (more primitive and mediates survival behaviors) such as fear, aggression, mating, and affection |
| Choroid Plexus | Secretes cerebrospinal fluid |
| Cerebellum | Controls balance coordination and control of voluntary movement, and fine muscle control but does not initiate movement |
| Brainstem | Controls breathing, body temp, digestion, alertness, sleep, and swallowing |
| The older adults goes through many changes within the brain | Includes loss of weight and volume with the thinning of cerebral cortex. Reduced subcortical brain structures and expansion of ventricles |
| The older adult goes through many changes with musculoskeletal | Includes general loss of muscle bulk, loss of muscle tone in the face, neck, and around spine. Decreased muscle strength, impaired fine coordination and agility, loss of vibratory sense at ankle, and absent Achilles reflex |
| The older adult goes through many changes with the eyes | Includes pupillary miosis, irregular pupil shape, and decreased pupillary reflexes |
| The older adult goes through many changes with the nerves | Includes velocity of nerve conduction decreasing and making reaction time slower. Increased delay at synapse resulting in diminished sensation of touch, pain, taste, and smell |
| The older adult goes through many changes with motor function | Includes motor system generally slowing down in movement. Muscle strength and agility decrease |
| The older adult goes through many changes with cardiovascular | Includes progressive decrease in cerebral blood flow and oxygen consumptions that may cause dizziness and loss of balance |
| It is important to note that not every neurological change is normal for older patient's | The nurse needs to assess for normal and abnormal such as balancing issues and paresthesia. The abnormal changes can be an indication for a stroke, brain injury, or other neurological issues |
| The sensory pathway consists of | Millions of sensory receptors embroidered into the skin, mucous membranes, muscles, tendons, and viscera. |
| The sensory pathway is responsible for | Monitoring the internal organ functions, conscious sensation, body position, and reflexes. |
| Sensations travel up the | afferent fibers in the peripheral nerves, through the posterior root, and into the spinal cord where it is either sent to the anterolateral tract or posterior columns. |
| The anterolateral tract is responsible for | transmitting the sensations of pain, temperature, itch, and crude touch, to the thalamus via sensory neurons where it is carried to the sensory cortex for full interpretation |
| The posterior dorsal columns are responsible for | Conducting the sensations of position or proprioception, vibration, and finely localized touch as shown in stereognosis |
| Proprioception | Knowing where your body parts are in space and in relation to one another without looking |
| Stereognosis | Identifying a familiar object by touch, without looking |
| Corticospinal/Pyramidal Tract | Originates in the pyramidal-shaped cells in the motor cortex. It is higher and newer, and permits humans to have a very skilled and purposeful movement, such as writing |
| Extrapyramidal Tract | Includes all motor nerve fibers that have originated in the basal ganglia, brainstem, and spinal cord outside of the pyramidal tract. It is lower and older, and responsible for maintaining muscle tone and control of body movements such as walking |
| Cerebellar System | A complex motor system that occurs on a subconscious level and coordinates movement, maintains equilibrium, and helps maintain posture |
| Visceral Reflexes | Includes the reflex arc of the autonomic nervous system which produces a glandular or non-skeletal muscular response in internal organs like the heart, blood vessels, organs in GI tracts |
| Examples of visceral reflexes are | sneezing, coughing, swallowing, vomiting, dilation of pupil, contraction of smooth muscles of the hollow organs in different organ systems |
| Deep tendon reflexes | Are surface reflexes on the body and include the biceps, brachioradialis, triceps, patellar, and achilles |
| The Bicep and brachioradialis reflex is assessing | C5 and C6 |
| The triceps reflex is assessing | C6 through C8 |
| The patellar reflex is assessing | L2-L4 |
| The Achilles reflex is assessing | S1 and S2 |
| The parasympathetic nervous system | Slows HR, increases gastric secretion, empties the bladder, focuses eye on near vision, constricts pupil and contracts bronchial smooth muscle. It is known as rest and digest |
| The parasympathetic nervous is located | In the brainstem and in the spine from S2 through s4, the neurotransmitter is acetylcholine |
| The sympathetic nervous system | Regulates the cardiovascular system, regulating body temperature, and implementing the acute stress response. It is known as the fight or flight |
| the sympathetic nervous system is located | In the spine from T1 through L2. The major neurotransmitter is epinephrine or adrenaline |
| Sympathetic nervous system body responses | Includes dilation of pupils, inhibition of salivation, relaxes bronchi, accelerates HR, inhibits peristalsis and secretion, stimulates glucose production & release, secretes adrenaline and noradrenaline, inhibits bladder contraction, and stimulates orgasm |
| Wernicke Area | is associated with damage to the temporal lobe and effects language comprehension. The patient will hear the noise but will not understand the meaning termed receptive aphasia |
| Broca's Area | is associated with damage to the frontal lobe and effects speaking and writing. The patient will not be able to speak and will haven difficulty with writing language. Their words will sound like garble. Terms expressive aphasia |
| The areas to be assessed in a neurological assessment include | cognitive, LOC, motor, sensory, and reflexes |
| In a basic neurological assessment | Assess sensory such as touch, temperature sense, any issues with reflexes? Are they awake and alert? Can they remember what you said 10 mins ago? |
| Rooting Reflex | Brush the infant's cheek near the mouth. Note whether they turn their head toward the side touched. Appears at birth and disappears by 3 to 4 months |
| Plantar Grasp | Place baby's head midline. Offer your finger from the babies ulnar side. Note the tight hold; sucking should increase the hold, often can pull baby up by the hold. Appears at birth, strongest at 1 to 2 months, disappears at 3 to 4 months |
| Tonic Neck Reflex | Place baby supine, relaxed, or sleeping, turn head to one side with the chin over shoulder. Note ipsilateral extension of the arm &leg and flexion of the opposite arm & leg (fencing) Appears at 2 to 3 months, decreases and then disappears by 4 to 6 months |
| Morro Reflex | Startle the infant & they will look like they are hugging a tree Note symmetric abduction & extension of arms and legs, fanning fingers and curling of the index finger and thumb to C Position occur, then brings arms in. Appears at birth till 1 to 4 months |
| Level of consciousness terms | Alert, confusion, drowsiness, stupor, coma |
| Alert | Patient appreciates the environment and responds quickly to stimuli and is awake |
| Confusion | Patient is disoriented to time, place, or person, has shortened attention span, shows poor memory or has difficulty following commands |
| Drowsiness | Patient responds to stimuli appropriately but with delay and slowness; may respond to some but not all. Also called lethargy or obtunded state |
| Stupor | Patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation |
| Coma | Patient is unresponsive and generally cannot be aroused |
| What assessment tool should we use for LOC assessments | Glasgow Coma Scale |
| What do we assess in LOC | Eye opening, verbal response, and motor response |
| What is the order for assessing LOC | Spontaneously, Normal voice, loud voice, tactile, noxious |
| Romberg Test | Ask patient to stand with eyes closed, do they sway |
| Moderate swaying during Romberg Test indicates | vestibulocerebellar disfunction. |
| Severe swaying during Romberg Test indicates | Lesion in posterior columns of the spinal cord |
| Gait Assessment | Abnormal gait include spastic hemiparesis, scissors, parkinsonian, cerebellar ataxia, sensory ataxia, waddling, dystonia, and athetoid |
| Cerebellar Function Assessment | Finger to nose coordination, rapid alternating movement of hands on the thighs, heel to shin |
| Light touch assessment | Use cotton swab |
| Superficial Pain Sensation Assessment | Break tongue blade or cotton swab and use sharp end |
| Hyperesthesia | Increased touch sensation |
| Anesthesia | Absent touch sensation |
| Hypesthesia | Reduced touch sensation |
| Hyperalgesia | Increased pain sensation |
| Analgesia | Absent pain sensation |
| hypalgesia | Reduced pain sensation |
| Temperature Sensation | Have the patient close their eyes and use something warm and then cold and have them determine the difference |
| Point Localization | Have patient close their eyes and gently touch a part of their extremities and abdomen, have them identify where you are touching |
| Vibration Sense | Use tuning fork and have the patient close their eyes. Strike and place over bony prominences, beginning in most distal. Mostly used in diabetic neuropathy patients |
| Kinesthesia or position sense | Move a finger or toe up or down and have them determine which |
| Sterogenesis | Test ability to feel objects and identify object |
| Graphesthesia | Trace a letter or number on the patients hand and have them identify |
| Extinction | Touch the patient on both sides of the body at the same point, have them identify |
| Two point discrimination | Test the ability of a patient to distinguish the separation of two simultaneous pin points in the skin. Note the distance at which the person no longer perceives two separate points |
| S1 Is it heard best at the base or the apex? | loudest at the Apex |
| S1 is it heard in Systole or Diastole? | Beginning of Systole |
| S1 which valves closing make this sound? | AV valves Mitral and Tricuspid |
| S2 is it heard best at the base or the apex? | loudest at the base |
| S2 is it heard in Systole or Diastole? | Beginning of Diastole |
| S2 What valves closing make this sound? | Semilunar valves Aortic and Pulmonic |
| S3 is it heard in systole or diastole? | Early Diastole after S2 |
| What causes the sound of S3? | Rapid filling of the ventricles which causes turbulence and vibrations. |
| S3 is heard with what disease processes? | CHF and MI |
| Is S3 ever a normal sound? | S3 may be normal in children and young adults. |
| S3 is it an atrial or ventricular gallop? | Venticular |
| S4 is it heard in Systole or Diastole? | Late diastole before S1 |
| What causes the sound of S4? | Atrial kick into a noncompliant ventricle. |
| S4 is heard with what disease processes? | CAD, Hypertension, Aortic Stenosis |
| S4 is this ever a normal sound? | S4 is generally considered an abnormal sound |
| S4 is this an atrial or ventricular gallop? | Atrial |
| What is the best patient position to hear S3 and S4? Supine? Semi Fowlers? Left lateral position? | Lying in the left lateral position shifts the heart closest to the chest wall |
| Which of the four heart sounds is the only one heard during systole? | S1 |
| Systolic murmur is heard after which valves close? | AV valves |
| Systolic murmur does it occur between S1 and S2 or between S2 and S1? | Between S1 and S2 |
| Diastolic murmur is heard after which valves close? | Semilunar valves (Aortic and Pulmonic) |
| Does Diastolic murmur occur between S1 and S2 or between S2 and S1 | between S2 and S1 |
| What is Hemodynamics? | The Physics of Blood flow |
| What is Compliance? | The amount a vessel will stretch due to a change in pressure. |
| Which is more compliant veins or arteries? | Veins-Think vericose veins how they stretch |
| Which is less compliant veins or arteries? | Arteries-Think of hardening of the arteries |
| What is Isovolumetric contraction? | The point at which all 4 heart valves are closed for an instant just after the ventricles have filled |
| Does Isovolumetric contraction happen during Systole or Diastole? | At the beginning of Systole |
| Does Isovolumetric contraction happen before or after S1? | After S1 and before S2 |
| What is Isovolumetric relaxation? | The point at which all 4 heart valves are closed for an instant just after the atrium have filled |
| Does Isovolumetric relaxation happen during Systole or Diastole? | At the beginning of Diastole |
| Does Isovolumetric relaxation happen before or after S1? | Before S1 and after S2 |
| What does a pericardial friction rub sound like? Soft and Quiet? or High pitched and scratchy like sandpaper? | High pitched and scratchy like sandpaper |
| What patient position is best to hear a pericardial friction rub? Supine taking a deep breath in? or Sitting up, leaning forward, with breath held in expiration? | Sitting up, leaning forward, with breath held in expiration. |
| What is a mnemonic to remember the order of the valves in the heart? | Tissue Paper My Assets=Tricuspid, Pulmonic from the right side, Mitral, Aortic from the left side. |
| Where do you listen to the Aortic valve sound? | 2nd intercostal space at the right sternal border. |
| Where do you listen to hear the Pulmonic valve sound? | 2nd left intercostal space |
| Where do you listen to hear Erb's point? | 3rd left intercostal space |
| Where do you listen to hear the Tricuspid valve sound? | 4th left intercostal space |
| Where do you listen to hear the Mitral valve sound? | 5th left intercostal space |
| Where do you auscultate the Apical pulse? | 5th left intercostal space midclavicular line |
| Where do you palpate the point of maximal impulse (PMI) or apical impulse? | 5th left intercostal space midclavicular line |
| What is a mnemonic for remembering where to listen to the valve sounds? | APE To Man=Aortic, Pulmonic, Erb's point, Tricuspid, Mitral, starting from 2nd right intercostal space across to 2nd left and then down |
| Why do you listen to the heart valves in a different location than where the valves are? | Because the sound radiates with the direction of blood flow. |
| Of S1, S2, S3, S4. Which heart sound coincides with the Carotid Artery Pulse? | If you feel the carotid and auscultate at the apex the sound you hear when you feel each pulse is S1 |
| What can you do to hear the heart sounds better? | Have the Patient sit up and lean forward or roll to their left (and “breathe out” and “hold it” but not too long) to place the heart closest to the chest wall, Turn down the TV, close the door, place the stethoscope on skin not over clothing. |
| If the point of maximal impulse (PMI) is palpated at the 6th intercostal space. Is that normal or abnormal? | Generally considered Abnormal |
| What could be a cause of the heart sounding muffled or distant? | Fluid around the heart-Cardiac Tamponade |
| What would cause the PMI to be palpable at the 6th (ICS)-intercostal space? | (Cardiomegaly)-Enlargement of the heart or (Myocardiopathy)- any disease causing enlargement of the heart. |
| What would cause enlargement of the heart? Swelling your chest as you breathe in deeply? Increased ventricular volume? Increased ventricle wall thickness? | Increased ventricular volume and Increased ventricle wall thickness. |
| Which of these medical conditions would cause the heart to enlarge when ventricular volume increases or the ventricle wall thickens? Hypertension, CAD, Heart failure, Cardiomyopathy? | All of them. |
| If the heart is enlarged how could this be veiwed? (EKG-ECG)-Electrocardiogram? Echocardiogram? Xray? Angiogram? | An enlarged heart with a shifted PMI (at the 6th intercostal space or greater) could be seen on Xray. |
| Are the superior and inferior Vena cava on the left or right side of the heart? | Right |
| Do the superior and inferior vena cava carry oxygenated or unoxygenated blood to the heart? | They carry unoxygenated blood from the body back to the right atrium |
| Does the Aorta carry oxygenated or unoxygenated blood out to the body? | Oxygenated |
| Is the Aorta on the right or left side of the heart? | Left side |
| Which carries “unoxygenated blood”- Pulmonary Arteries or Pulmonary Veins? | Pulmonary “ARTERIES” carry unoxygenated blood. The pulmonary system is the only place that arteries carry unoxygenated blood and veins carry oxygenated blood |
| Do the pulmonary arteries carry blood to the heart or the lungs? | Pulmonary arteries carry unoxygenated blood from the right side of the heart to the lungs |
| Do the pulmonary veins carry oxygenated or unoxygenated blood? | The pulmonary veins carry oxygenated blood. |
| Do the pulmonary veins carry blood to the left atrium or the lungs? | The pulmonary veins carry oxygenated blood from the lungs to the left atrium |
| Are there valves in the arteries or in the veins of our legs? | Their are valves in the veins of our legs that keep the blood from flowing back down with gravity. |
| Are there valves in the veins of your head? | The veins in our head have no valves they drain into our jugular veins that drain directly into the superior vena cava and into the right atrium. |
| If the right side of the heart fails to pump well and blood backs up how might this be seen? In the carotid arteries or In the Jugular veins? | Blood would back up and cause (JVD) Jugular vein distension. |
| What position of the patient might be best to observe JVD? Supine-lying down flat, Sitting straight up, or with the bed at a 30 to 45 degree angle? | With the bed at a 30 to 45 degree angle. (Lying down flat the jugular veins would not be so visible. Sitting straight up the veins would flatten and not be so visible.) |
| Is Jugular vein distension a sign of right sided or left sided heart failure? | Right sided heart failure as the right side fails to pump well the blood backs up into the “veins”. |
| Does JVD reveal pressure changes in the right side of the heart or volume changes in the right side of the heart? | Both. JVD would be a sign of right sided heart failure |
| True or False? Abnormally high pressure in the right side of the heart shows up in the neck veins and the abdomen. | True. This would be a sign of right sided heart failure |
| True or False? Abnormally high volume in the right side of the heart would show up in JVD, enlarged liver and spleen, dependant edema-(swollen hands and feet) and fatigue? | True. These are signs of right sided heart failure. Just think of where the veinous blood would back up to on the right side of the body and how gravity would take it back down to the liver and the hands and feet |
| True o False? Abnormally high pressure or volume in the left side of the heart would back blood up to the lungs? | True. |
| True or False? Abnormally high pressure or volume in the left side of the heart may show up as crackles in the lungs, cough, dyspnea on exertion, cyanosis, and increased “pulmonary”-capillary wedge pressure and blood tinged sputum? | True. These are all signs of Left sided heart failure. |
| refers to a visual exam of body, including body movement and posture | inspection |
| involves the use of the nurses hands tp feel texture, size, shape, consistency, and location | palpation |
| part of hands most sensitive to vibrations | ulnar surface of hands |
| part of hand that best detects position, texture, size, etc | palmar surface of hands (fingers and fingerpads) |
| the act of listening sounds within the body | auscultation |
| involves the striking of a finger or hand directly against a pt body | percusion |
| a loud, high-pitched sound heard over abdomen | tympany |
| is heard over normal lung tissue | resonance |
| is heard in overinflated lungs | hyperresonance |
| is heard over the liver | dullness |
| is heard over bones and muscles | flatness |
| what is the percussion tones of the lungs? | tone- resonant.....intensity- loud......pitch- low....duration- long.......quality- hollow |
| what is the percussion tones of the bones and muscles? | tone- flat....intensity-soft...pitch-high...duration-short...quality-extremely dull |
| what is the percussion tones of the viscera and liver borders? | tone-dull...intensity-medium...pitch-med high...duration-medium...quality-thudlike |
| what is the percussion tones of the stomach and gas bubbles in intestines? | tone-tympanic...intensity-loud...pitch-high...duration-medium...quality-drumlike |
| what is the percussion tones of the air trapped in lung? | tone-hyperresonant...intensity-very loud...pitch-very low...duration-longer...quality-booming |
| position used to assess head, neck, back, thorax, lungs, breasts, axillae, heart, vital signs, and upper extemities | sitting |
| position to assess head, neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses | supine |
| position used to assess head, neck, anterior thorax and lungs, breasts, axillae, heart, abdomen | dorsal recumbent |
| position used to assess female genitalia and gential tract | lithotomy |
| position used to assess rectum and vagina | sims |
| position used to assess musculoskeletal system | prone |
| position used to assess heart | lateral recumbent |
| position used to assess the rectum | knee-chest |
| Sense of Initiative versus Guilt | Preschooler: Age 3 to 6 |
| Sense of Integrity vs. Despair | Older Adult: Age 65 and older |
| Sense of Identity vs. Role Confusion | Adolescent: Age 12 to 20 |
| Sense of Generativity vs. Stagnation | Middle Adult: Age 45 to 65 |
| Sense of intimacy vs. Isolation | Young Adult : Age 20 to 45 |
| Sense of Industry vs. Inferiority | School Aged : Age 6 to 12 |
| Sense of Trust vs Mistrust | Infant : Birth to age 1 year |
| Sense of Autonomy vs. Shame and Doubt | Toddler: Age 1 to 3 |
| A 10 Year old boy proudly displays his principal's award certificate. | Industry vs. Inferiority |
| An Infant believes that his parents will feed him. | Trust vs. Mistrust |
| 22 year old woman picks a circle of friends with whom she spends her free time. | Intimacy vs. Isolation |
| 13 y.o. girl fights with her mother about appropriate dress. | Identity vs. Role Confusion |
| A nursing home resident reflects positiviely on her past life experiences. | Ego Integrity vs. Despair |
| A 15 year old boy worries about how his classmates treat him. | Identity vs. Role Confusion |
| A 45 year old man meets a goal of guiding his two children into rewarding careers. | Generativity vs. Stagnation |
| A Kindergarten student learns the ABC's. | Initiative vs.Guilt |
| A 2 year old boy expresses interest in dressing himself. | Autonomy vs. Shame and Doubt |
| A 35 year old woman volunteers Sat. Mornings to work with the homeless. | Generativitiy vs. Stagnation |
| What are the layers of the skin? | Epidermis, dermis & the subcutaneous layer of adipose tissue. |
| What is the epidermis layer? | The thin but tough outer layer of the skin that forms a rugged protective barrier. |
| What is melanin? | It gives brown tones to the skin and the hair. |
| The inner basal cell layer forms new skin cells. What is the name of the tough fibrous protein? | Keratin |
| What is the dermis? | The inner supportive layer of the skin consisting mostly of connective tissue or collagen. The dermis also contains elastic tissue so the skin can stretch. |
| What part of the skin are the nerves, sensory receptors, blood vessels and lymph glands in? | The dermis |
| What is the function of the subcutaneous layer(adipose tissue)? | The subcutaneous tissue stores fat for energy, provides insulation for temperature control, and aids in protection by its soft cushioning effect. The also gives increased mobility over the structures underneath. |
| What is hair made up of? | Keratin |
| What is a freckle? | A small macules of melanin pigment that occur on sun exposed skin. |
| What is a mole (nevus)? | A proliferation of melanocytes, tan to brown in color, flat or raised. |
| What is pallor? | When the red to pink tones from the oxygenated hemoglobin in the blood are lost, skin is then pale. |
| What is erythema? | Erythema is an intense redness from excess blood in the dilated superficial capillaries. |
| What is cyanosis? | A bluish color that signifies decreased perfusion, the tissues do not have enough oxygenated blood. |
| What is jaundice? | A yellowish skin color indicates a rising amount of bilirubin in the blood. |
| What is a cherry angioma? | A small (1 to 5 mm), smooth, slightly raised bright red dot that appears on the skin of adults. They normally increase in size and number with aging and are not significant. |
| What are senile lentigines? | Commonly called liver spots. These are small, flat, brown macules. |
| What are keratoses? | These lesions are raised, thickened areas of pigmentatin that look crusted, scaly and warty. |
| What are acrochordons or skin tags? | An overgrowth of normal skin that forms a stalkand are polyp-like. They occure frequently on eyelids, cheeks, cheeks, neck, axillae and truck. |
| What is skin turgor? | A decrease in elasticity and the skin recedes slowly or "tent" and stands by itself. |
| What is a macule? | A color change in the sckin which is flat and is less than 1 cm. |
| What is a nodule? | A skin lesion that is solid, elevated, hard or soft, and larger than 1 cm. May extend into the dermis. |
| What is a papule? | A skin lesion that you can feel (Example, solid, elevate, and less than 1 cm in diameter) caused by sperficial thickening in the epidermis. |
| What is a wheal? | A skin lesion which is superficial, raised, transient, erythematous, slightly irregular shae due to the edeume. Example a mosiquite bite. |
| What is a vesicle? | An elevated containing free fluid , up to 1 cm; a "blister." Clear serum flows if the wall is ruptured. |
| What is petechiae? | Tiny pin like hemmorrhages, 1 to 3 mm, round and dscrete, dark red, purple or brown in color. |
| What is ecchymosis? | A purplish patech resulting from extravasationof blood into the skin. > 3 mm in diameter. |
| Where are the parotid glands? | In the cheeks over the mandible, anterior to and below the ear. |
| Where are the submandibular glands? | Beneath the mandible at the angle of the jaw. |
| Where are the sublingual gands? | In the fllor of the mouth. |
| Where is the temporal artery? | Superior to the temporalis muscle; its pulsation is palpabe anterior to the ear. |
| What is the lacrimal apparatus? | Provides constant irrigation to keep the conjunctiva and cornea most and lubricated. |
| What is presbyopia? | Decrease in the lens's ability to change shape to accommodate for near vsion. |
| What is exophthalmos? | Protruding eyes |
| What is enophthalmos? | Sunkin eyes |
| What is ectropion? | Lower eye lid drooping |
| What is entropion? | Lower eye lid turning in |
| What is ptosis? | Drooping upper eye lid |
| What is the tympanic membrane? | The eardrum, separates the external and the middle ear. |
| What is the pinna? | Auricle or the external ear |
| What is cerumen? | Ear wax |
| What is the uvula? | The free projection hanging down from the middle of the soft palate. |
| What is the frenulum? | The midline fold of tissue that connects the tongue to the floor of the mouth. |
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