Download NR 304 exam 2024, health assessment II, cranial nerves, heart sounds, reflex grading, abdo and more Exams Nursing in PDF only on Docsity!
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palpation of radial pulse - ☑️☑️☑️ Palpate both pulses noting the rate, rhythm, elasticity of vessel wall and equal force
grading pulse - ☑️☑️☑️ 3+ full bounding 2+ normal 1+ weak 0 absent
brachial pulse - ☑️☑️☑️ palpate this pulse if you suspect arterial insufficiency
modified Allen's test - ☑️☑️☑️ tests for ulnar arterial insufficiency by occluding both the radial and ulnar artery normal results: normal color of hand should reappear approximately 2-5 seconds abnormal results: pallor persists or a sluggish return to color suggest occlusion of the collateral arterial flow
temporal artery - ☑️☑️☑️ palpated in front of the ear
carotid artery - ☑️☑️☑️ palpated in the groove b/t the sternomastoid muscle and the trachea
brachial artery - ☑️☑️☑️ major artery supplying the arm
radial artery - ☑️☑️☑️ lies medial to the radius and wrist supplies blood to the hand
ulnar artery - ☑️☑️☑️ lies lateral to the ulna. Deeper and often difficult to feel. Supplies blood to the hand
femoral artery - ☑️☑️☑️ major artery in the leg. Palpated in the inguinal area
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popliteal artery - ☑️☑️☑️ artery in the knee. Located posterior to the patella. Divides into the anterior and posterial tibial artery
anterior tibial - ☑️☑️☑️ travels down the front of the leg on to the dorsal of the foot becomes the dorsalis pedis. carries blood to the anterior compartment of the leg and dorsal surface of the foot
posterior tibial - ☑️☑️☑️ travels down behind the medial malleolus and forms the plantar arteries in the foot. carries blood to the posterior compartment of the leg and plantar surface of the foot
dorsalis pedis - ☑️☑️☑️ a blood vessel of the lower limb that carries oxygenated blood to the dorsal surface of the foot
claudication distance - ☑️☑️☑️ the number of blocks walked or stairs climbed to produce pain
arterial claudication - ☑️☑️☑️ pain in the calf, thigh or hip or muscle fatigue that occurs when walking a certain distance related to peripheral arterial disease (PAD)
peripheral perfusion - ☑️☑️☑️ checking for capillary refill by blanching the nail beds and noting the time for color return normal is less than 1-2 seconds
doppler - ☑️☑️☑️ used if pulses are too weak to detect by palpation, monitor blood pressure in infants or children, measure low blood pressure or blood pressure in the lower extremities A noninvasive test using sound waves to detect blood flow through blood vessels ex. competent valves (varicosities)
edema - ☑️☑️☑️ fluid build up in the interstitial space
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-elevated pallor
venous insufficiency - ☑️☑️☑️ - normal temperature -normal pulse -flaky, dry, thick skin -skin tears easily- friable -edema -brawny color
arterial ulcers - ☑️☑️☑️ -intermittent claudication pain -no edema -no pulse or weak pulse -no drainage -round smooth sores -black eschar -location on toes and feet
venous ulcers - ☑️☑️☑️ -dull achy pain -lower leg edema -pulse present -drainage o sores w/ irregular borers o yellow slough or ruddy skin -location on ankles
vascular bruit - ☑️☑️☑️ an audible vascular sound associated w/ turbulent blood flow
heaves - ☑️☑️☑️ lift, a sustained forceful thrusting of the ventricle during systole. Occurs w/ ventricular hypertrophy as a result of increased workload right ventricular is seen at the sternal border left ventricular is seen at the apex
thrill - ☑️☑️☑️ palpable vibration. Feels like the throat of a purring cat. Signifies turbulent blood flow and directs you to the location of the origin of loud murmurs
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S1 - ☑️☑️☑️ Lub. Closure of the AV valves. Heard at the apex of the heart, correlation w/ the carotid artery, signified that systole is starting
S2 - ☑️☑️☑️ Dub. Heard at the base of the heart. closure of the semilunar valves. Indicates that diastole is starting and systole is ending
AV valves - ☑️☑️☑️ tricuspid and mitral valves. Close during systole to prevent regurgitation of blood back up into the atria. Filling phase during diastole
Semilunar valves - ☑️☑️☑️ pulmonic and aortic valve. Opens during systole to allow blood to be ejected from the heart
systole - ☑️☑️☑️ S1 close of AV valves S2 openof the semilunar valves
base - ☑️☑️☑️ top of the heart
apex - ☑️☑️☑️ bottom of the heart
S3 - ☑️☑️☑️ Lub-dupPA heart murmur, occurs when the ventricles are resistant to filling during the early rapid filling phase. occurs after S2 during rapid filling phase when the AV valves open and atrial blood first pours into the ventricle (heard at the apex, low pitch, heart failure, heart overload)
S4 - ☑️☑️☑️ fourth heart sound. DaLub-dup. occurs at the end of diastole at pre-systole (before S1) when the ventricle is resistant to filling A stiff wall (outflow stenosis, HTN, stiff ventricle)
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present at 1-4 months abnormal: absence of reflex or presents after 5 months indicates severe CNS injury
plantar grasp - ☑️☑️☑️ touch your thumb at the ball of the baby's foot, note the toes curl down tightly, reflex present at birth and disappear at 8-10 months
palmar grasp - ☑️☑️☑️ offer finger from the baby's ulnar side away from the thumb, tight grasp of the baby's fingers present at birth, strongest at 1-2 months and disappears at 3-4 months abnormal- reflex absent w/ brain damage and local muscle or nerve injury, after 4 months indicates frontal lobe lesion
tonic neck reflex - ☑️☑️☑️ when you turn the baby head to the side and the arms and legs will extend and the opposite will flex. Appears at 2-3 months and disappears at 4-6 months abnormal- indicates brain damage
Babinski reflex - ☑️☑️☑️ take the baby foot and make a upside down J,baby toes should go in a fanning motion (+ test in infants) present at birth and disappears by 24 months abnormal- present at 2 years occurs w/ pyramidal tract disease (motor) , in adults
spinothalamic test - ☑️☑️☑️ pain light touch vibration position (kinesthesia) tactile discrimination (fine touch) stereognosis graphesthesia two point discrimination extinction point location
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conscious - ☑️☑️☑️ promptly and spontaneously to state their name, location, date , time are said to be oriented to self, place and time ability to interact appropriately w/ in the context of the immediate environment
confused - ☑️☑️☑️ does not respond quickly w info about their name, location and the time poor attention
delirious - ☑️☑️☑️ restless agitated hallucinations
somnolent - ☑️☑️☑️ excessive drowsiness, mumbles
obtunded - ☑️☑️☑️ decreased interest in surrounding, slowed response
stuporous - ☑️☑️☑️ unresponsive and requires vigorous stimulation (painful) for arousal; once aroused the patient may be confused, agitated, unable to follow commands
comatose - ☑️☑️☑️ does not make this response to stimuli, have no corneal or gag reflex, and they may have no pupillary response to light
CN I - ☑️☑️☑️ olfactory nerve, smell
CN II - ☑️☑️☑️ optic, sensory, visual acuity, pupillary reflex ocular fundus test: Snellen Chart,
CN III, IV, VI - ☑️☑️☑️ EOM
-oculomotor (superior rectus, inferior rectus and oblique, medial rectus) -Trochlear (superior oblique) -Abducens (lateral rectus)
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hypoalgesia - ☑️☑️☑️ decreased pain sensation
analgesia - ☑️☑️☑️ absent pain sensation
hyperalgesia - ☑️☑️☑️ increased pain sensation
light touch test - ☑️☑️☑️ spinothalamic test, apply a wisp of cotton to the skin ask person to say yes when the touch is felt. CN V, VII (if on face, corneal reflex)
hypoesthesia - ☑️☑️☑️ decreased touch sensation
anesthesia - ☑️☑️☑️ absent touch sensation
hyperesthesia - ☑️☑️☑️ increased touch sensation
vibration - ☑️☑️☑️ spinothalamic test, tests the persons ability to feel vibrations of a tuning fork over bony prominences. Ask pt when the vibrations starts and stops abnormal- unable to feel vibrations, loss of vibration sense occurs w/ peripheral neuropathy (diabetes, alcoholism)
position (kinesthesia) - ☑️☑️☑️ tests the persons ability to perceive passive movements of the extremities. move a finger or big toe up and down and ask pt to tell you which way it is moved abnormal- loss of position sense
tactile discrimination - ☑️☑️☑️ fine touch test, measured the discrimination ability of the sensory cortex abnormal: lesions of the sensory cortex or posterior column
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stereognosis - ☑️☑️☑️ tests the persons ability to recognize objects by feeling their forms, size and weights. place a familiar object in the person hand and ask pt to identify it. abnormal: asterognosis
asterognosis - ☑️☑️☑️ inability to identify object correctly occurs in sensory cortex lesions (stroke)
graphesthesia - ☑️☑️☑️ the ability to "read" a number by having it traced on the skin. A good measure of sensory loss if the person cannot make the hand movements needed for sterognosis
two point discrimination - ☑️☑️☑️ tests the persons ability to distinguish the separation of two simultaneous pin point on the skin. Apply two point of an opened paper clip to the skin note the distance which the person no longer perceives two separate points
mental status exam - ☑️☑️☑️ measures appearance, behavior, thought process and cognition
parathesia - ☑️☑️☑️ numbness, losing ability to feel
cerebellar test - ☑️☑️☑️ -rapid alternating movements (RAM) -finger to finger test -finger to nose test -heel to shin test -gait -Romberg test -heel to toe (tandem walking)
rapid alternating test - ☑️☑️☑️ cerebellar test, ask the person to pat the knees w/ both hand and turn over and pat knees. should be done with equal turning and a quick, rhythmic pace abnormal- lack of coordination, slow, clumsy and sloppy response
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Arms- can client raise both arms equallt (arm drift) Speech- slurred speech or inappropriate words or mute Time- EMERGENCY
Parkinson's disease - ☑️☑️☑️ death of dopamine generating cells in midbrain
symptoms of Parkinson's disease - ☑️☑️☑️ -slow rigid movement -dementia -stoop posture -shuffling gait -pill rolling -tremors -bradykinesia -rigidity -impaired balance -small handwriting
Bell's palsy - ☑️☑️☑️ unilateral paralysis or weakness of the muscles on one side of your face
symptoms of Bell palsy - ☑️☑️☑️ -facial droop on one side of the face -numbness -difficulty blinking eye on affected side
apical pulse - ☑️☑️☑️ site where you hear the combination of both the S1 and S2 heart sounds at the 5th ICS
hypoactive bowel sounds - ☑️☑️☑️ absent bowel sounds caused by constipation, ileum, abdominal surgery, inflammation of the peritoneum
hyperactive bowel sounds - ☑️☑️☑️ borborygmus, loud, high-pitched, rushing tinkling sounds that signal increased motility causes: diarrhea, hunger, smokers, GI distress, caffeine, laxatives
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ileus - ☑️☑️☑️ minimal or no bowel motility absent or hypoactive bowel sounds (can't chart until after 5 mins)
percussion of the abdomen - ☑️☑️☑️ tympani and dullness sounds. Move clockwise Dullness over distended bladder, adipose tissue. fluid or mass hyper-resonance is present w/ gaseous distension tympany- drum sound, hollow
Liver span - ☑️☑️☑️ Normal liver is 5-10 cm located in the RUQ
splenic dullness - ☑️☑️☑️ in the mid-axillary line 6-10th ICS normal is <7cm.
CVA tenderness - ☑️☑️☑️ fist percussion. Causes the tissue to vibrate instead of producing sound used to assess the kidney. located on the 12th ICS on the back pt should feel a thud but no pain abnormal- inflammation of the kidney or paranephric area
light palpation of the abdomen - ☑️☑️☑️ 1-2 cm. to feel for superficial organs and tumors. abnormal- muscle guarding, large masses, tenderness
deep palpation of abdomen - ☑️☑️☑️ 5-8 cm Feeling for deep organs
abdominal aortic aneurysm (AAA) - ☑️☑️☑️ most common >95%, located below the renal arteries and extend to the umbilicus. Focal palpable bulge. symptoms- decreased femoral pulse. The enlargement of the aorta, the main blood vessel that delivers blood to the body symptoms- pulsation near the naval, deep constant pain in abdomen, back pain
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peritonitis signs and symptoms - ☑️☑️☑️ - abdominal guarding -abdominal distension and rigidity -"board like" abdomen -fever > -anorexia o nausea and vomiting o increase in pulse -increase in BP -decrease bowel sounds -dehydration -shock
cholecystitis - ☑️☑️☑️ inflammation of the gallbladder
iliopsoas muscle test - ☑️☑️☑️ perform test when the acute abdominal pain of appendicitis is suspected. when the person is supine, lift the right leg straight up, flexing at the hip; push down over the lower part of the right thigh as the person tries to hold the leg up. test is negative if the person feels no change
obturator test - ☑️☑️☑️ test for suspected appendicitis. lift patients right leg, flexing at the hip and 90 degrees to the knee hold his or her ankle and rotate the leg internally and externally. Should be no pain
peritonitis - ☑️☑️☑️ inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen caused by a rupture in the abdominal wall (ruptured appendix, pancreatitis, diverticulitis, trauma)
internal hemorrhage - ☑️☑️☑️ loss of blood that occurs from the vascular system into a body cavity or space symptoms light-headedness dizziness syncope
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indigestion - ☑️☑️☑️ pain or discomfort in the stomach associated w/ difficulty in digesting food. Underlying symptom of GERD, ulcers and gallbladder disease
GERD, gastroesophageal reflux disease - ☑️☑️☑️ -digestive disease in which the stomach acid (bile) irritates the food pipe lining -a complex of symptoms of esophagitis, including burning in midepigastrium or behind lower sternum that radiates upward or "heartburn". Occurs 30-60 mins after eating, aggravated by lying down or bending over
organs in the RUQ - ☑️☑️☑️ -liver -gallbladder -duodenum -head of pancreas -right kidney and adrenal -hepatic flexure of colon -part of ascending and transverse colon
organs in the LUQ - ☑️☑️☑️ -stomach -spleen -left lobe of liver -body of pancreas -left kidney and adrenal -splenic flexure of colon -part of transverse and descending colon
organs of the RLQ - ☑️☑️☑️ -cecum -appendix -R ovary and tube -R ureter -R spermatic cord
organs of the LLQ - ☑️☑️☑️ -part of descending colon -sigmoid colon
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Gout - ☑️☑️☑️ sodium urate crystal (uric acid) build up in the joint causing extreme pain, redness, heat and swelling see in the big tose, limits ROM in olecranon process if in upper extremities
scoliosis - ☑️☑️☑️ lateral curvature of thoracic and lumbar segments of the spine
kyphosis - ☑️☑️☑️ common during adolescents due to poor chronic posture. excessive convex is the thoracic region. "hunch back"
lordosis - ☑️☑️☑️ common in infants and pregnancy. Exaggeration of the anterior convex curve of the lumbar spine
ataxia - ☑️☑️☑️ loss of full control of bodily movements
older adult musculoskeltal system - ☑️☑️☑️ - decreased Ca absorption -reduced osteoblast production -chronic illnesses and medication -kyphosis -degeneration of joints -fibrous or stringy muscle fibers -shortening of vertebral column -loss of subcutaneous fat -osteoporosis -lifestyle affects musculoskeletal changes
myalgia - ☑️☑️☑️ cramping or aching muscle pain
conditions caused by RA - ☑️☑️☑️ Swan neck Boutennier deformity
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Swan neck - ☑️☑️☑️ caused by RA accompanied by ulnar drift. Flexion contracture resembles curve of a swans neck in the distal interphalangeal joint
Boutonniere deformity - ☑️☑️☑️ A common deformity and includes flexion of the proximal interphalangeal joint w/ compensatory hyperextension of the distal IPJ
OA deformities - ☑️☑️☑️ -Herberden nodules -Bouchards nodules
Herbeden nodules - ☑️☑️☑️ hard non tender nodule that occurs in the distal IP nodes
Bouchards nodules - ☑️☑️☑️ hard non tender nodule that occurs in the proximal IP joint, less common
genu valgum - ☑️☑️☑️ knock knees, present when there is more than 2.5 cm b/t the medial malleoli when the knees are together occurs w/ rickets, polimyelitis and syphilis
genu varum - ☑️☑️☑️ bowlegs, one or both legs bent outward at knee
tail of spence - ☑️☑️☑️ the upper outer quadrant of the breast. common site of most breast tumors
areola - ☑️☑️☑️ small circular area, the ring of pigmented skin surrounding a nipple
nipple - ☑️☑️☑️ located just below the center of the breast. Rough, round and usually protuberant. surface looks wrinkled and indented w/ tiny milk duct opening
lobes - ☑️☑️☑️ 15-20 loves radiating from the nipple that are composed of lobules
