Exam 2 Review PDF

What is the purpose of percussion? (pp 111-113) a. Percussion has the following uses: i. mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors ii. signaling the density (air, fluid,...

What is the purpose of percussion? (pp 111-113) a. Percussion has the following uses: i. mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors ii. signaling the density (air, fluid, or solid) of a structure by characteristic note iii. detecting an abnormal mass if it is fairly superficial; The percussion vibrations penetrate about 5 centimeters deep-a deeper mass would give no change in percussion iv. eliciting a deep tendon reflex using the percussion hammer During a physical assessment describe the inspection phase. (p 111) b. Inspection is close, careful scrutiny, first of the individual as a whole and then of each body system. It begins the moment you first meet the person and develop a "general survey". It requires good lighting, adequate exposure, and occasional use of certain instruments to provide additional light and/or enlarge your view. Essentially, inspection is concentrated watching. How does an otoscope work? (p 115) c. An otoscope funnels light into the ear canal and onto the tympanic membrane or inside the nares. During palpation what techniques are used? (p 111) d. Different parts of the hands are best suited for assessing different factors: v. Fingertips- best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps. vi. A grasping action of the fingers and thumb- to detect the position, shape, and consistency of an organ or mass. vii. The dorsa (back) of hands and fingers- best for determining temperature because the skin is thinner than on the palms. viii. Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand- best for vibration e. Your palpation technique should be slow and systematic, calm and gentle. Warm your hands by needing them together or holding them under warm water. Identify any tender areas and palpate them first. f. Start with light palpation to detect surface characteristics and to accustom the person to being touched. Then perform deeper palpation. With deep palpation intermittent pressure is better than one long, continuous palpation. Avoid any situation in which deep palpation could cause internal injury or pain. What is the first technique used during a physical assessment? (p 111) g. Inspection always comes first. Percussion over dense organs produce what sounds? (p 113) h. Percussion over dense organs like the liver or spleen will produce a dull sound with a soft amplitude, high pitch, muffled thud quality, at a short duration. What types of sounds do you hear when using a diaphragm of a stethoscope? (p 113) i. The diaphragm, because of its flat edge, is best for high pitched sounds. This includes breath, bowel, and normal heart sounds. Why do we use a Doppler device? (p 157) j. The Doppler is used to locate the peripheral pulse sites. What are the steps to an assessment and how should they be performed? (pp 111-114) k. The steps to a nursing assessment include: ix. Inspection - See question 2. x. Palpation - See question 4. xi. Percussion - See question 1. xii. Auscultation - Auscultation is listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen. This is done using a stethoscope. - Before you evaluate body sounds, you must eliminate any confusing artifacts: - Any extra room noise can produce a roaring in your stethoscope; Therefore, the room must be quiet. - Keep the examination room warm, and warm your stethoscope. This can be done by rubbing the end piece in your palm. - The friction and the end piece from a man\'s hairy chest causes a crackling sound that mimics an abnormal breath sound called *crackles*. To minimize this problem, wet the hair before auscultating the area. - Never listen through a gown. This can create artifactual sound and muffle any diagnostically valuable sound from the heart or lungs. - Avoid your own "artifact", such as breathing on the tubing or the "thump" from bumping the tubing. - Use the diaphragm to listen for high-pitched sounds- breath, bowl, and normal heart sounds. - Hold the diaphragm firmly against a person\'s skin, firm enough to leave a slight ring afterward. - Use the bell endpiece for soft, low-pitched sounds- extra heart sounds or murmurs. - Hold the bell lightly against the person\'s skin, just enough that it forms a perfect seal. Holding it any harder causes the person\'s skin to act as a diaphragm, obliterating the low-pitched sounds. When should you wash your hands during an assessment? (p 117) l. Hand washing should be performed before and after every physical patient encounter. A. What are orthostatic blood pressures? (p 151) m. Orthostatic blood pressures are serial blood pressures used to assess for orthostatic hypotension. This refers to a drop in systolic pressure of greater than or equal to 20 mmHg or diastolic pressure greater than or equal to 10 mmHg after changing to a standing position. B. How do you take them? a. Have the person rest supine for at least three minutes, but preferably for 5 minutes, then take baseline blood pressure and pulse readings. Have the patient sit up and assess blood pressure and pulse; Then have the patient stand and assess blood pressure and pulse. Finally, after the patient has been standing for three minutes, assess blood pressure and pulse. C. Who should get them? a\. Serial measurements of pulse and blood pressure should be taken when: xiii. You suspect volume depletion xiv. When the person is known to have hypertension or is taking antihypertensive medications xv. When the person reports syncope or near syncope 12. In an older adult what are likely seen for vital sign measurements? (p 155) n. Normal range of findings for the aging adult include: xvi. Temperature- changes in the body\'s temperature regulatory mechanism leave the older adult less likely to have a fever but at a greater risk for hypothermia. Thus the temperature is less reliable index of the older person\'s true health state. Sweat gland activity is also diminished. xvii. Pulse- the normal range of heart rate is 50 to 95 beats/min, but the rhythm may be slightly irregular. The radial artery may feel stiff, rigid, and tortuous in an older person, although this condition does not necessarily imply vascular disease in the heart or brain. The increasingly rigid arterial walls needs a faster stroke of blood, so the pulse is actually easier to palpate. xviii. Respirations- aging causes a decrease in vital capacity and a decreased inspiratory reserve volume. You may note a shallower inspiratory phase and an increased respiratory rate. xix. Blood pressure- the aorta and major arteries tend to harden with age. As the heart pumps against a stiffer aorta, the systolic pressure increases, leading to a widened pulse pressure. With many older people, both the systolic and diastolic pressures increase, making it difficult to distinguish expected aging values from abnormal hypertension. 13. What assessment findings do you see with acromegaly? (p 138) o. Acromegaly is the excessive secretion of growth hormone in adulthood after normal completion of body growth causes overgrowth of bone in face, head, hands, and feet but no change in height. Internal organs also enlarge and metabolic disorders may be present. So you will see a larger head, hands, and feet in relation to the rest of the body. 14. What complaints do you see with radiation heat loss? (p 141) I specifically asked this question to Maggie, and she said "know the difference between external heat loss  (ex. radiation, conduction, ect) and internal heat loss (metabolism)." p. The book states that the thermostat balances heat production (from metabolism, exercise, food digestion, external factors) with heat loss (through radiation, evaporation of sweat, convection, conduction). 15. Blood pressure is measured by what five factors? (pp 147-148) q. The level of blood pressure is determined by 5 factors: xx. *Cardiac output*. If the heart pumps more blood into the container (i.e., the blood vessels), the pressure on the container walls increases. xxi. *Peripheral vascular resistance*. Peripheral vascular resistance is the opposition to blood flow through the arteries. When the container becomes smaller, the pressure needed to push the contents becomes greater. Conversely, if the container becomes larger, less pressure is needed. xxii. *Volume of circulating blood.* Volume of circulating blood refers to how tightly the blood is packed into the arteries. Increasing the contents in the container increases the pressure. xxiii. *Viscosity.* The thickness of blood is determined by its formed elements, the blood cells. When the contents are thicker, the pressure increases. xxiv. *Elasticity of vessel walls.* When the container walls are stiff and rigid, the pressure needed to push the contents increases. 16. What are guidelines for weighing patients? (p 129) r. Use a standardized *balance* or electronic standing scale. Instruct the person to remove shoes and heavy outer clothing before standing on the scale. When a sequence of repeated weights is necessary, aim for approximately the same time of day and the same type of clothing worn each time period record the weight in kilograms and in pounds. 17. What are causes of unexplained weight loss? (p 129) s. An unexplained weight loss may be a sign of a short-term illness (e.g., fever, infection, disease of the mouth or throat) or a chronic illness (e.g., endocrine disease, malignancy, depression, anorexia nervosa, bulimia nervosa). 18. What is a tripod position and what is it used for? (p 128) t. The tripod position is when a patient leans forward with arms braced on a chair or other surface; this occurs with chronic pulmonary disease, such as COPD, giving them leverage so the abdominal, intercostal, and neck muscles all can aid in expiration. 19. What is the correct technique for counting a pulse? (pp 144-145) u. Using the pads of your first three fingers, palpate the radial pulse at the flexor aspect of the wrist laterally along the radius bone. If the rhythm is regular, count the number of beats in 30 seconds and multiply by two. Although the 15 second interval is frequently practiced, any one beat error in counting results in a recorded error of four beats/min. The 3o-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. However, if the rhythm is irregular, count for a full minute. As you begin the counting interval, start your count with "zero" for the first pulse felt. The second full pulse felt is "one", and so on. Beginning the count at "one" overestimates the heart rate. 20. What is neuropathic pain? (pp 165-166) v. Neuropathic pain is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is pain due to a lesion or disease in the somatosensory nervous system. It implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat. Pain is often perceived long after the site of injury heals, and it evolves into a chronic condition. 21. What are examples of visceral pain? (p 166) w. Visceral pain originates from the larger internal organs such as the stomach, intestine, bladder, and pancreas. It often is described as dull, deep, squeezing, or cramping. The pain can stem from direct injury to the organ or stretching of the organ from tumor, ischemia, distension, more severe contraction. Examples of visceral pain include ureteral colic, acute appendicitis, ulcer pain, and cholecystitis. 22. What is a faces pain scale and who is it for? (p 171) x. The faces pain scale is a pain scale used for children starting around the age of 4. The faces pain scale has 6 drawings of faces that show pain intensity, from "no pain" on the left to "very much pain" on the right. It has realistic facial expressions, with a furrowed brow and horizontal mouth. It avoids smiles or tears so that children will not confuse pain intensity with happiness or sadness. 23. What objective data would you see with uncontrolled pain? (p 173) y. Poorly controlled acute pain and chronic pain have a negative impact on physiologic systems. Objective data includes the following: xxv. Cardiac - tachycardia, elevated blood pressure, increased myocardial oxygen demand, increased cardiac output xxvi. pulmonary - hypoventilation, hypoxia, decreased cough, atelectasis xxvii. gastrointestinal - nausea, vomiting, ileus xxviii. Renal - oliguria, urinary retention xxix. musculoskeletal - spasms, joint stiffness xxx. endocrine - increased adrenergic activity xxxi. central nervous system - fear, anxiety, fatigue xxxii. immune - impaired cellular immunity, impaired wound healing xxxiii. poorly controlled chronic pain - depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life 24. What is the best indicator of pain? z. Self-report 25. Patients with chronic pain exhibit what? (p 173) What are examples of nonverbal behaviors associated with chronic pain? (p 173) a. Chronic pain behaviors have even more variability than acute pain behaviors. People with chronic pain typically try to give little indication that they are in pain and therefore are at higher risk for under detection. Behaviors associated with chronic pain include bracing, rubbing, diminished activity, sighing, and change in appetite. Whenever possible, it is best to ask the person about pain behaviors. Chronic pain behaviors such as spending time with other people, movement, exercise, prayer, sleeping, or inactivity underscore the more subtle, less anticipated ways in which people behave when they are experiencing chronic pain. 26. What are examples of acute pain? (p 166) b. Examples of an acute pain include surgery, trauma, and kidney stones. 27. What are the phases of nociception? (pp 164-165) c. There are 4 phases of nociception. They include: xxxiv. Transduction - Occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery. These injured tissues then release a variety of chemicals including substance P, histamine, prostaglandins, serotonin, and bradykinin. These chemicals transmit a pain message, or action potential, along sensory afferent nerve fibers to the spinal cord. A second set of neurotransmitters carries the pain impulse across the synaptic cleft to the dorsal horn neurons. These neurotransmitters include substance P, glutamate, and adenosine triphosphate. xxxv. Transmission - The pain impulse moves from the level of the spinal cord to the brain. At the site of the synaptic cleft within the spinal cord are opioid receptors that can block pain signaling with endogenous opioids or with exogenous opioids if they are administered. However, if not stopped, the pain impulse moves to the brain via various ascending fibers within the spinal thalamic tract to the thalamus. Once the pain impulse moves through the thalamus, the message is dispersed to higher cortical areas. xxxvi. Perception - Signifies the conscious awareness of a painful sensation. Cortical structures such as the limbic system account for the emotional response to pain, and the somatosensory areas can characterize the sensation. Only when the noxious stimuli are interpreted in these higher cortical structures can the sensation be identified as "pain\". xxxvii. Modulation - Fortunately our bodies have a built in mechanism that will eventually slow down and stop the processing of a painful stimulus. If not for pain modulation, the experience of pain would continue from childhood injuries to adulthood period to inhibit and block the pain impulse, descending pathways from the brain stem to the spinal cord release a third set of neurotransmitters that produce an analgesic effect. These neurotransmitters include serotonin, norepinephrine, neurotensin, GABA, and our own endogenous opioids. 28. What is the difference between deep somatic, referred, and visceral pain? (p 166) d. Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Referred pain is pain that is felt at a particular site but originates from another location. Visceral pain originates from the larger internal organs like the stomach, intestine, gallbladder, and pancreas. Somatic pain originates from musculoskeletal tissues or the body surface. Cutaneous pain is derived from skin surface and subcutaneous tissues. 29. What are findings of jaundice? (p 209/227) e. Jaundice occurs with hepatitis, cirrhosis, sickle cell disease, transfusion reaction, and hemolytic disease of the newborn. In the eyes, the sclera yellow of jaundice extends up to the edge of the iris. You may also see yellow in the heart palette, mucus membranes, and over the skin. Do not mistake normal yellowish fatty deposits in the sclera periphery for jaundice; Jaundice best noted in junction of hard and soft palate, also in the palms of the hands. 30. What is skin turgor, how do you assess for it, and what is considered abnormal? (p 210) f. Skin turgor reflects the elasticity of the skin. It is the skin's ability to return to place promptly. To test for this, pinch up a large fold of skin on the anterior chest under the clavicle. Release the skin and assess its ability to return to its normal place. Poor turgor is evident in severe dehydration or extreme weight loss; The pinched skin recedes slowly or "tents" and stands by itself. 31. What causes bilateral edema or edema that is generalized over the entire body? (p 210) g. Bilateral edema or edema that is generalized over the whole body (anasarca) is typically caused by heart failure or kidney failure. 32. What causes our hair to turn gray? (p 213) h. Graying hair begins as early as the 30s because of reduced melanin production in the follicles. 33. What are the stages of ulcers? (p 234) i. There are multiple stages to ulcers, also known as pressure injuries. These include: xxxviii. Stage 1- Non-blanchable erythema - Intact skin is red but unbroken. Localized redness in lightly pigmented skin does not blanch. Dark skin appears darker but does not blanch. May have changes in sensation, temperature, or firmness. xxxix. Stage 2- Partial-thickness skin loss - Loss of epidermis and exposed dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed. No visible fat or deeper tissue. xl. Stage 3- Full-thickness skin loss - Pressure injury extends into subcutaneous tissue and resembles a crater. See subcutaneous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon. xli. Stage 4- Full-thickness skin/ tissue loss - Pressure injury involves all skin layers and extends into supporting tissue. Exposes muscle, tendon, or bone, and may sloth or eschar, rolled edges, and tunneling. xlii. Deep tissue pressure injury - Localized, non-blanchable color change to deep red, maroon, purple intact or non intact skin. Dark skin appears darker but does not blanch. Or, epidermis may separate, revealing dark wound or blood-filled blister. Preceded by pain and temperature change period begins in the muscle closest to the bone, in older adults and those with lower BMI, commonly on skin over coccyx, sacrum, buttocks, heels. xliii. Pressure injury caused by medical device - skin or mucosa has pressure injury that looks like pattern or shape of medical device. Skin pressure injuries should be staged; Mucosal pressure injury cannot be staged. Rigid plastic of medical device is necessary to maintain shape and function of object but causes pressure on underlying skin and mucosa. 34. What is the difference between a wheal and a papule? (p 230) j. A wheal is superficial, raised, transient, and erythematous; Slightly irregular shape from edema. Examples include a mosquito bite, allergic reaction, dermographism. k. A papule is something you can feel caused by superficial thickening in epidermis. Examples include elevated nevus (mole), lichen planus, molluscum, wart. 35. Define xerosis. (p 203) l. Dry 36. What drugs increase sunlight sensitivity and give a burn response, and what education are you going to give the patient about this? (p 204/223) m. Drugs that increase sunlight sensitivity include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline. Education to patients taking these drugs should include use of sunscreen, hats, and long sleeved tops during outdoor sports and beach or pool activities. 37. What are the criteria when assessing clubbing of the fingernails? (p 214) n. Assessing for clubbing entails "The Profile Sign". This is done by viewing the index finger at its profile and noting the angle of the nail base. It should be about 160°. The nail base is firm to palpation. Curved nails are a variation of normal with a convex profile. They may look like clubbed nails, but notice that the angle between nail base and nail is normal. In early clubbing the angle straightens out to 180°, and the nail base feels spongy to palpation. Then the nail becomes convex as the digit grows. In late clubbing the inner edge of the nail elevates; Nail bed angle is greater than 180°. Distal phalanx looks rounder, wider, and shiny. 38. What is the difference between a cluster headache and a tension headache? (pp 271-272) o. Tension headaches xliv. Usually occur on both sides , across frontal, temporal, and/or occipital region of the head: forehead, sides, and back of head. xlv. Characterized by bandlike tightness, vicelike Nonthrobbing, nonpulsatile. xlvi. Duration is typically 30 minutes to seven days with a gradual onset. xlvii. Quality is diffuse, dull aching pain xlviii. Severity is mild to moderate. xlix. Timing is situational, in response to overwork, or posture. p. Cluster headaches l. Always one sided, behind or around the eye, or temple. li. Characterized by continuous, sharp, burning, piercing, or excruciating pain. lii. Duration is approximately 15 to 180 minutes with an abrupt on set. liii. Quality is that they can occur multiple times a day in "clusters" lasting weeks. liv. Severity is very severe. lv. Timing is one to two per day up to 8 per day for weeks or months; then remission for months or years. They often occur at night or when waking from sleep. 39. What objective data do you find with an elevated T4 and T3 hormone level? (p 277) q. Continuous increased production of thyroid hormones causes an increased metabolic rate, just like ramping up the furnace, causing hyperthyroidism, or Graves\' disease. This is manifested by goiter, eyelid retraction, and exophthalmos (bulging eyeballs). 40. What are the two major neck muscles that are innervated by cranial nerve XI? (p 252) r. The major neck muscles innervated by cranial nerve XI are the *sternomastoid* and the *trapezius* muscles. 41. How can you tell the difference between a cancerous tumor and a non-cancerous tumor? (pp 262, 207-208) s. Cancerous nodes are hard (feel like a rock), unilateral, non-tender, matted, and fixed to adjacent structures. Non-cancerous nodes are the opposite. t. Abnormal characteristics of pigmented lesions are summarized in the pneumonic ABCDEF: lvi. Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, Elevation or Evolution, Funny looking. 42. Where are the four areas in the body that lymph nodes are accessible? (p 255) u. Lymph nodes are located throughout the body but are accessible to examination in only four areas: the head and neck, arms, axillae, and inguinal region. 43. What characteristics in older adults do you see with their faces? (p 267) v. In the aging adult the temporal arteries may look twisted and prominent. In some aging adults a mild rhythmic tremor of the head may be normal. Isolated head tremors are benign and include head nodding and tongue protrusion. If some teeth have been lost, the lower face looks unusually small, with the mouth sunken in. The neck may show an increased anterior cervical curve when the head and jaw are extended forward to compensate for kyphosis of the spine. During the examination direct the older adult to perform ROM slowly; They may experience dizziness with side movements. An older adult may have prolapse of the submandibular glands, which could be mistaken for a tumor. But drooping submandibular glands feels soft and are present bilaterally. Many older adults have low lying thyroid glands that are impossible to palpate. The gland lies behind the sternomastoid muscles and clavicles. 44. When palpating the temporomandibular joint for crepitation where is this located? (p 260) w. The temporomandibular joint is just below the temporal artery and anterior to the tragus. 45. How do you palpate the lymph nodes in one's neck? (p 261) x. Lymph nodes are palpated using a gentle circular motion of your finger pads. Strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, comparing the two sides symmetrically. However, the submental gland under the tip of the chin is easier to explore with one hand. When you palpate with one hand use your other hand to position the person\'s head. For the deep cervical chain, tip the person\'s head toward the side being examined to relax the ipsilateral muscle. Then you can press your fingers under the muscle. Search for the supraclavicular node by having the person hunch the shoulders and elbows forward; This relaxes the skin. The inferior belly of the omohyoid muscle crosses the posterior triangle here; Do not mistake it for a lymph node. Beginning with the preauricular lymph nodes in front of the ear, palpate the ten groups of lymph nodes in routine order. Many nodes are closely packed, so you must be systematic and thorough in your examination. Once you establish your sequence, do not vary or you may miss some small nodes. The 10 groups of lymph nodes that you will palpate, in order, include the preauricular, posterior auricular, occipital, submental, submandibular, jugulodigastric, superficial cervical, deep cervical chain, posterior cervical, and supraclavicular nodes.