UTA NURS 3320 Assessment Final Exam
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| Light palpation depth | 1 cm
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| Deep palpation depth | 5-8 cm (2-3")
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| Location of Liver | RUQ; Left lobe LUQ
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| Location of Gallbladder | RUQ
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| Location of Duodenum | RUQ
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| Location of Pancreas | Head RUQ; Body LUQ
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| Location of Right kidney | RUQ
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| Location of Stomach | LUQ
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| Location of Spleen | LUQ
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| Location of Left kidney | LUQ
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| Location of Cecum | RLQ
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| Location of Appendix | RLQ
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| Location of Ovary & tube | RLQ/LLQ
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| Location of ureter | RLQ/LLQ
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| Location of spermatic cord | RLQ/LLQ
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| Location of Sigmoid colon | LLQ
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| Location of Ascending colon | RUQ/RLQ
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| Location of transverse colon | RUQ/LUQ
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| Location of Descending colon | LUQ/LLQ
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| Location of Aorta | Midline
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| Location of Uterus (if enlarged) | Midline
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| Location of Bladder (if distended) | Midline
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| Where tympany is heard | should predominate because air in the intestines rises to the surface when the person is supine.
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| Where Dullness is heard | occurs over a distended bladder, adipose tissue, fluid, or a mass
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| General survey components | physical appearance, body structure, mobility, and behavior.
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| Orthostatic hypotension | a drop in systolic pressure of more than 20 mm Hg or orthostatic pulse increases of 20 bpm or more occurs with a quick change to a standing position.
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| Orthopenea | difficulty breathing when supine.
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| Speculum size for Otoscope inspection | largest that fits comfortably
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| Head position for Otoscope inspection | slightly away from you toward the opposite shoulder
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| Straighten ear canal by pulling pinna _______ on an adult | up and back
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| Straighten ear canal by pulling pinna _______ on an child (< 3yrs) | down and out
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| Position to hold otoscope | "upside down" along your fingers with dorsa (back) of your hand along person's cheek braced to steady otoscope.
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| Position of ophthalmoscope | Hold the ophthalmoscope right up to your eye, braced firmly against the cheek and brow. Match sides with the person.
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| Diopter | unit of strength of each lens on an ophthalmoscope
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| PQRST | Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity Scale, Timing, Understand Patient's Perception
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| Symptom | subjective sensation that the person feels from the disorder
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| Sign | an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports
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| subjective data | what the person says about himself or herself.
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| objective data | what you observe through measurement, inspection, palpation, percussion, and auscultation.
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| General Survey purpose | Get an ovreall impression, a "gestalt," of a person
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| Delirium | an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.
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| Dementia | a gradual progressive process, causing decreased cognitive function, even though the person is fully conscious and awake, and is not reversible. Alzheimer disease accounts for about 2/3 of cases of dementia in older adults. Not part of normal aging.
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| Alert LOC | Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately, conducts meaningful interpersonal interactions.
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| Lethargic (or Somnolent) LOC | Not fully alert, drifts off to sleep, can be aroused to name when called in normal voice but looks drowsy, responds appropriately to questions/commands, thinking slow/fuzzy, inattentive, loses train of thought, decreased spontaneous movements
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| Obtuned | Sleeps most of time, difficult to arouse—needs loud shout or vigorous shake, acts confused when is aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation.
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| Stupor or Semi-Coma | Spontaneously unconscious, responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.
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| Coma | Completely unconscious, no response to pain or to any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away), light coma has some reflex activity but no purposeful movement, deep coma has no motor response.
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| CVA s/s | Sudden weakness, usually ipsilateral; sudden confusion, trouble speaking, or understanding, sudden vision change; sudden trouble walking; sudden severe headache
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| Parkinsons s/s | Posture stooped; trunk pitched forward; elbows, hips, & knees flexed. Steps short & shuffling. Hesitation to begin walking, & difficult to stop suddenly. Holds body rigid. Walks and turns body as one fixed unit. Difficulty with any change in direction.
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| Right Hemisphere | Visual spatial skills; expressing emotion; concentration & attention; sense of direction
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| Left Hemisphere | Language; speech; reading & writing; math; verbal communication
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| Frontal lobe | contains primary motor cortex; personality, behavior, emotions, and intellectual function; Precentral gyrus (voluntary movement); Broca's area (speech)
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| Precentral gyrus | in the frontal lobe; initiates voluntary movement.
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| Broca's area | in the frontal lobe; mediates motor speech. When injured in the dominant hemisphere, expressive aphasia results.
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| Parietal lobe | contains primary sensory cortex; position sense, touch, shape, & texture of objects
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| Postcentral gyrus | in the Parietal lobe; the primary center for sensation.
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| Temporal lobe | behind the ear; the primary auditory cortex; Wernicke's area (language comprehension); interprets auditory, visual & somatic input; hearing, taste, and smell.
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| Occipital lobe | the primary visual cortex; receives visual information.
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| Wernicke's area | in the temporal lobe; associated with language comprehension. When damaged in the person's dominant hemisphere, receptive aphasia results. The person hears sound, but it has no meaning, like hearing a foreign language.
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| Basal ganglia | create smooth, coordinated voluntary movement by balancing the production of acetylcholine & dopamine (neurotransmitters) – Automatic movements like arm swing alternate with legs when walk
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| Thalamus | Relay station for the nervous system; Sensory pathways of the spinal cord and brainstem form synapses
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| Hypothalamus | (Homeostasis); Temperature, HR, BP, sleep center; ANS responses; Storage & secretion of pituitary gland hormones
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| Cerbellum | motor coordination of voluntary movements, equilibrium & muscle tone; hemisphere controls ipsilateral side of body
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| Midbrain | relay info r/t muscle movement to brain
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| Pons | Relays senosry info; regulates respiration
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| Medulla | involuntary functions (e.g., breathing)
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| CN I | Olfactory - Smell
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| CN II | Optic - Vision
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| CN III | Oculomotor - Extraocular Movement, opening eyelids; pupil constriction, lens shape
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| CN IV | Trochlear - Down & inward eye movement
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| CN V | Trigeminal - mastication muscles; sensation of face & scalp, cornea, mucous membranes of mouth and nose
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| CN VI | Abducens - Lateral eye movement
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| CN VII | Facial - facial muscles, close eye, labial speech, close mouth; taste (sweet, salty, sour, bitter) on anterior two thirds of tongue; saliva and tear secretion
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| CN VIII | Acoustic - Hearing & equilibrium
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| CN IX | Glossopharyngeal - pharynx movement (phonation & swallowing); taste on posterior 1/3 of tongue, pharynx (gag reflex); parotid gland, carotid reflex
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| CN X | Vagus - Pharynx & larynx movement (talking & swallowing); sensation from carotid body, carotid sinus, pharynx, viscera; carotid reflex
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| CN XI | Spinal Accessory - Trapezius & sternomastoid muscle movement
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| CN XII | Hypoglossal - tongue movement
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| Dorsiflexion | Flexion of the ankle (tibiotalar joint)
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| Plantar flexion | Extension of the ankle (tibiotalar joint)
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| Flexion | bending a limb at a joint
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| Extension | straightening a limb at a joint
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| Abduction | moving a limb away from the midline of the body
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| Adduction | moving a limb toward the midline of the body
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| Pronation | turning the forearm so that the palm is down
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| Supination | turning the forearm so that the palm is up
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| Circumduction | moving the arm in a circle around the shoulder
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| Inversion | moving the sole of the foot inward at the ankle
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| Eversion | moving the sole of the foot outward at the ankle
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| Rotation | moving the head around a central axis
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| Protraction | moving a body part forward and parallel to the ground
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| Retraction | moving a body part backward and parallel to the ground
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| Elevation | raising a body part
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| Depression | lowering a body part
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| Osteoarthritis | Noninflammatory, localized, progressive disorder involving deterioration of articular cartilages and subchondral bone and formation of new bone (osteophytes) at joint surfaces.
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| Rheumatoid Arthritis | Chronic, systemic inflammatory disease of joints and surrounding connective tissue. symmetric and bilateral and is characterized by heat, redness, swelling, and painful motion of the affected joints.
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| ROM of Spine | flexion (bending forward), extension (bending back), abduction (to either side), and rotation
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| CHF s/s | Dilated pupils; pale/gray/cyanotic cool/moist skin; Dyspnea/Orthopnea, Crackels/Wheeze/Cough; low BP; n/v; Ascites; edema; Anxiety; low O2; Confusion; Jug vein distention; Fatigue; S3 gallop, tachycardia; enlarged spleen/liver; low urine; Weak pulse
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| S1 | First heart sound. Beginning of systole. Caused by closure of AV valves.
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| S2 | Second heart sound. End of systole. Caused by closure of semilunar valves
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| S3 | Third heart sound. Heard immediately after S2. Ventricle filling sound heard at apex (left-sided) or LSB (right-sided). Dull, soft sound, and low pitched, like "distant thunder".
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| Physiologic S3 | heard frequently in children and young adults; it occasionally may persist after age 40 years, especially in women. The normal S3 usually disappears when the person sits up. (Jarvis 2012, p. 491)
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| Pathologic S3 | Ventricular gallop or S3 gallop. Persists when sitting. indicates decreased compliance of the ventricles, as in heart failure.
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| S4 | Fourth heart sound. Heard just before S1. Ventricular filling sound heard when atria contract late in diastole. Very soft & low-pitched.
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| Physiologic S4 | may occur in adults older than 40 or 50 years with no evidence of cardiovascular disease, especially after exercise. (Jarvis 2012, p. 491)
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| Pathologic S4 | Atrial gallop or S4 gallop. Left-sided occurs with coronary artery disease, cardiomyopathy, systolic overload, including outflow obstruction to the ventricle (aortic stenosis) and systemic HTN. Right-sided occurs with pulmonary stenosis or pulmonary HTN.
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| COPD s/s | Hypertrophied neck muscles; sitting in tripod position; Tense, strained, tired face; Pursed lips; Accessory muscles to force expiration.
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| Pneumothorax s/s | Unequal chest expansion; Decreased fremitus; Hyperresonance; Diminished breath sounds.
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| Atelectasis s/s | Collapse: Cough; Decreased ches expansion (on affected side); Decreased fremitus; Tracheal shift toward affected side; Dull; Deminished breath sounds; May hear fine crackles.
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| Pulmonary Embolism s/s | Chest pain; dyspnea; Respiratory alkalosis; Diaphoresis; Hypotension; Tachycardia; Cracles, wheezes.
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| Acute Respiratory Distress Syndrome (ARDS) s/s | Acute dyspnea; thin, frothy sputum; Respiratory alkalosis; pulmonary infiltrates; Hypotension; Tachycardia; Crackles, ronchi.
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| Bronchial breath sounds | Located in trachea & larynx. High pitched, loud, harsh, hollow tubular. Inspiration < expiration.
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| Bronchovesicular breath sounds | Located over bronchi: btwn scapulae, around upper sternum in 1st & 2nd ICS. Moderate pitch, moderate sound. Inspiration
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| Vesicular breath sounds | Located over peripheral lung fields. Low pitched, soft, rustling. Inspiration > expiration.
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| Glaucoma s/s | Increased intraocular pressure; decrease in peripheral vision
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| Acute (Narrow-angle) glaucoma s/s | circumcorneal redness; pupil oval/dilated; cornea looks "steamy"; sudden clouding of vision, eye pain, & halos around lights.
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| Chronic (open-angle) glaucoma s/s | Excessive Cup-Disc ratio; Painless; No early s/s; gradual peripheral vision loss, eventually tunnel vision if untreated
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| Cataracts s/s | Lens opacity resulting from a clumping of proteins in the lens. (Jarvis 2012, p. 285)
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| Macular degeneration s/s | breakdwon of cells in the macula of the retina; loss of central vision.
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| Corneal abrasion s/s | Top layer of corneal epithelium removed, from scratches or poorly fitting or overworn contact lenses. Feel intense pain, a foreign body sensation, and lacrimation, redness, and photophobia.
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| Abnormal tonsils | acute infection: bright red & swollen (2+ to 4+) and may have exudate or large white spots. Mononucleosis, leukemia, or diptheria: white membrane covering tonsils.
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| Normal tonsils | pink, peppered with indentations (crypts) that may collect small plugs of whitish debris. No exudate. No swelling (1+ or 2+)
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| Grade 1+ Tonsils | Visible
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| Grade 2+ Tonsils | Halfway between tonsillar pillars and uvula
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| Grade 3+ Tonsils | Touching the uvula
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| Grade 4+ Tonsils | Touching eachother
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| Dizziness | light-headed, swimming sensation, feeling of falling
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| Vertigo | rotational spinning from neurologic disease
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| Nursing process steps | Assessing, Diagnosing, Planning, Implementing, Evaluating
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| Steps to Cultural Competency | Self-understanding; Identify the meaning of HEALTH to other people; Understand the health care delivery system; Know about social background of your patients; Be familiar with the language people speak & resources to interpret
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| Assimilation | the process by which a person develops a new cultural identity and becomes like the members of the dominant culture
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| Spirituality | Arising from each person’s unique life experience and the personal effort to find purpose and meaning in life
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| Underweight BMI | <18.5 (adults) or <5th percentile (children)
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| Normal BMI | 18.5-24.9 (adults) or 5th-85th percentile (children)
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| Overweight BMI | 25-29.9 (adults) or 85th-95th percentile (children)
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| Obese BMI | ≥30 (adults, extreme if ≥40) or ≥95th percentile (children)
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| Glucose Normal | <100 mg/dL
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| HbA1c Normal | 5-7%
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| Hemoglobin Normal | males—14 to 18 g/dL, females—12 to 16 g/dL
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| Hematocric Normal | males—37% to 49%, females—36% to 46%
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| LDL Cholesterol Normal | <130 mg/dL
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| HDL Cholesterol Normal | men, 35-65 mg/dL; women, 35-80 mg/dL
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| Triglycerides Normal | <150 mg/dL
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| Serum Albumin Normal | 3.5 to 5.5 g/dL
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| Serum Transferrin Normal | 170 to 250 mg/dL
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| Prealbumin Normal | 15 to 25 mg/dL
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| C-reactive protein (CRP) Normal | <0.1 mg/dL
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| Hyperactive Bowel Sounds | Loud, gurgling sounds, “borborygmi,” signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus.
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| Hypoactive Bowel Sounds | Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia.
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| Aortic Aneurysm s/s | Most (>95%) located below renal arteries & extend to umbilicus. Focal bulging >5 cm is palpable in abt 80% of cases and feels like a pulsating mass in the upper abdomen just to the left of midline. Bruit is heard. Femoral pulses are present but decreased.
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| Red Reflex | Red glow filling pupil when Ophthalmoscope light reflects off inner retina. Opaque black areas against red reflex is sign of Cataracts.
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| Allen test | Picture cards used to screen visual acuity of children from 2 1/2 to 2 yrs and 11 months.
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| Modified Allen test | evaluates adequacy of collateral circulation before cannulating the radial artery. Depress radial & ulnar arteries; open/close fist; release ulnar. Normal if blood returns or occluded if no blood return.
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| Respiratory distress s/s | tachypnea/bradypnea, low O2 sat, cap refill >2 secs, use of accessory muscles, adventitious or decreased breath sounds, anxiety, pallor, diaphoresis (due to work of breathing), unable to complete sentences when speaking due to shortness of breath.
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| Elevated Hgb & Hct | Polycythemia vera or dehydration
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| Decreased Hgb & Hct | Anemia, recent hemorrhage, or hemodilution caused by fluid retention
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| Elevated Cholesterol or Triglycerides | increased risk for coronary artery disease
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| Decreased Serum Albumin & Transferrin | Protein-calorie malnutrition, altered hydration status, and decreased liver function
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| Elevated Prealbumiin | renal desease
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| Decreased Prealbumin | surgery, trauma, burns, and infection
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| Elevated CRP | increased risk for atherosclerosis, infections, rheumatoid arthritis, TB; contraceptive use & last 4-5 months of pregnancy
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