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UTMB SON Fall 13 Nurs 334 0
Health Assessment- Vitals Test
With Solution
Where Heat is lost from body - ANSWER Skin (Radiated), Sweat (Evaporation), Warming and humidifying inspired air, Urine/Feces
Ways Heat is lost/transferred - ANSWER Radiation, Convection, Conduction, Evaporation
5 Routes for taking temperature - ANSWER oral, axillary, rectal, tympanic membrane, core temperature
Which method of taking Temperature is most accurate? - ANSWER Core
Questions to ask before oral temperature - ANSWER Eaten, drank or smoked recently, chewing gum, oral surgery/ability to hold thermometer
Hypothermia - ANSWER < 95f or 35c
Pyrexia - ANSWER Oral temperature >100.4f or 38c
Hyperpyrexia - ANSWER Oral Temperature >105.8f or 41c
Deviation of Axillary Temp from Oral - ANSWER - 1f
Contraindications for Axillary Temp - ANSWER Surgery or trauma to that arm/breast
Color for Rectal Thermometers - ANSWER RED
Deviation of Rectal Temp from Oral - ANSWER +1f
To "hit" the Tympanic Membrane in an Adult/Child - ANSWER Adult pull ear up and back - child down and forward
Positioning for rectal temperature - ANSWER Left Sims
3 way to measure core temperature - ANSWER rectal temperature, pulmonary thermistor, bladder thermistor
"Normal" Forehead Temperature - ANSWER 34.4 º C, 94.0 º F
Tympanic temperature is taken at - ANSWER the ear/ear drum
3 Stages of a fever - ANSWER Initiation, Plateau & Defervenscence
Kyphosis - ANSWER Humpback, An exaggerated posterior curvature of the thoracic spine that causes significant back pain and limited mobility.
lordosis - ANSWER Swayback exaggerated forward curvature of the lumbar and cervical regions of the spinal column
scoliosis - ANSWER an abnormal lateral curve to the vertebral column
Palpation - ANSWER An examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts.
Part of the hand best suited for feeling temperature - ANSWER The dorsa (backs) of hands and fingers
Percussion - ANSWER A diagnostic technique that uses tapping on the body to differentiate air, solids, and fluids
Auscultation - ANSWER Listening for sounds in blood vessels or other body structures, typically using a stethoscope.
In the Diagnose stage we.... - ANSWER Use Subjective and Objective Information to derive nursing Collaborative solution or referral
In the Planning stage we.... - ANSWER Determining outcome criteria and plan
In the Implementation stage we.... - ANSWER Carrying out the plan
In the Evaluation stage we.... - ANSWER Assess if the plan worked.
3 Parts of Communication: - ANSWER Sender - Message - Receiver
Open ended questions: - ANSWER Allow for discussion
Closed ended questions: - ANSWER Yes/No or few word answers
Laundry list: - ANSWER List of options to choose from
Rephrasing: - ANSWER Reflecting back to sender using different words to ensure clarity, express the same message in different words
To avoid Potential problem providing information: - ANSWER Ensure receiver understands the info
Inferring: - ANSWER Drawing a conclusion and expressing it, The process of making an inference, an interpretation based on observations and prior knowledge.
6 Non Verbal Communication Components: - ANSWER Posture, Gestures, Facial expression, Eye contact, Voice, Touch
3 Phases of Therapeutic Communication - ANSWER Introductory, Working and Closing
4 Types of Health History - ANSWER Comprehensive, Ongoing or partial, Focused or problem oriented, Emergency
Factors Affecting Respirations - ANSWER exercise, respiratory & CV illnesses, altered fluid & electrolytes, pain, infection, anxiety, trauma
3 Parts of Respiratory Assessment (R) - ANSWER rate, depth & rhythm, patterns
Factors Determining Systolic - ANSWER The characteristics of the stroke volume being ejected from the heart
The ability of the aorta to stretch and accommodate the stroke volume
Factors Determining Diastolic Blood Pressure - ANSWER The energy stored in the aorta as its elastic fibers are stretched during systole
The resistance to the runoff of blood from the peripheral blood vessels
Systolic pressure: - ANSWER pressure at the height of the pressure pulse, Maximum blood pressure. Occurs during contraction of the ventricles.
Diastolic pressure: - ANSWER measured at the lowest point of the waveform (normally 60 to 90 mm Hg). occurs in between the contractions of the atria and ventricles (or while the heart is at rest), as these chambers begin refilling with blood.
Pulse pressure: - ANSWER The difference between systolic and diastolic pressure
Vellus Hair - ANSWER The short, fine, and downy hair that helps in the efficient evaporation of perspiration is
Terminal Hair - ANSWER coarse, long hair found on the head, eyebrows, axillary and genital areas: growth stimulated by male sex hormones
Lesions - ANSWER areas of tissue that have been pathologically altered by injury, wound, or infection
freckles - ANSWER a small brownish spot (of the pigment melanin) on the skin
striae - ANSWER stretch marks
Cyanosis - ANSWER A bluish discoloration of the skin and mucous membranes. Sign of either low O2 or cold
Pallor - ANSWER Extreme paleness
Jaundice - ANSWER yellowing of the skin and the whites of the eyes caused
by an accumulation of bile pigment (bilirubin) in the blood
Acanthosis nigricans - ANSWER Epidermal hyperplasia with darkening of the skin (velvet like skin) often involves the axilla or groin
turgor - ANSWER Ability of skin to rebound after being stretched
Edema - ANSWER Abnormal accumulation of fluid in interstitial spaces of tissues.
Macule - ANSWER A circumscribed, flat, nonpalpable change in skin color < 1cm
Patch - ANSWER A irregular shaped, flat, nonpalpable change in skin color > 1cm
Papule - ANSWER A papule is a small solid elevation of the skin less than 0.5cm in diameter.
plaque - ANSWER A plateaulike elevated lesion greater than 0.5cm
Ulcer - ANSWER Loss of tissue extending past the epidermis, necrotic tissue loss, bleeding and scaring possible.
Fissure - ANSWER Linear crack in the skin, may extend to the dermis
Petechia - ANSWER a minute red or purple spot on the surface of the skin as the result of tiny hemorrhages of blood vessels in the skin (as in typhoid fever)
Ecchymosis - ANSWER Bruising, Black and blue skin discoloration caused by hemorrhage.
Hematoma - ANSWER A localized swelling filled with blood.
Cherry angioma - ANSWER noncancerous (benign) skin growth made up of blood vessels papular and round, red or purple, may blanch with pressure
Spider angioma - ANSWER Spider angioma is an abnormal collection of blood vessels near the surface of the skin.
Telangiectasis (Venous Star) - ANSWER Spider-like or linear, bluish or red in color, does not blanch, associated with increased venous pressure states.
A,B,C,D,E of Melanoma - skin cancer - ANSWER Asymmetry
Borders
Color
Diameter
Elevation
Manubriosternal angle - ANSWER The angle between the manubrium and the body of the sternum at the manubriosternal junction. Marks the level of the second costal cartilage (rib) for counting ribs or intercostal spaces. Denotes level of aortic arch, bifurcation of trachea, and T4/T5 intervertebral disc.
Suprasternal notch - ANSWER A depression easily felt at the base of the anterior aspect of the neck, just above the angle of Louis
Dyspnea - ANSWER Difficult and labored breathing, shortness of breath
Paroxysmal nocturnal dyspnea (PND) - ANSWER attacks of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep, and may be quite frightening. Though simple orthopnea may be relieved by sitting upright at the side of the bed with legs dependent (legs dangling), in a patient with paroxysmal nocturnal dyspnea, coughing
Atelectasis - ANSWER collapse of the expanded lung
Tripod position - ANSWER The tripod position is a physical stance often assumed by people who are in respiratory distress (such as COPD patients) or who are simply out of breath (such as a person who has just run a sprint). In tripod position, one sits or stands leaning forward and supporting the upper body with hands on the knees or on another surface. A patient adopting the tripod position is considered an indication that the patient may be in respiratory distress. In the setting of chest pain without labored respirations, the tripod position may indicate acute pericarditis.
It has been thought that the tripod position optimizes the mechanics of respiration by taking advantage of the accessory muscles of the neck and upper chest to get more air into the lungs
Parietal pleura - ANSWER Parietal pleura lines the thoracic wall, covers the superior surface of the diaphragm and separates the pleural cavity from the mediastinum.
Visceral pleura - ANSWER The visceral pleura is attached directly to the lungs, as opposed to the parietal pleura, which is attached to the opposing thoracic cavity.
Myopia - ANSWER NEARSIGHTEDNESS
Nystagmus - ANSWER Eyes drift off intended target then jerk back into position.
Cerumen - ANSWER Ear wax
Otalgia - ANSWER Pain in the ear
Vertigo - ANSWER Condition of dizziness,
Presbyopia - ANSWER Defined as: impaired near vision
Presbycusis - ANSWER A normative age-related loss of the ability to hear high-pitched tones.
Otorrhea - ANSWER Discharge from ear
Tinnitus - ANSWER Ringing in the ears
linings rubbing together[1] and can be described as the sound made by treading on fresh snow. They occur where the pleural layers are inflamed and have lost their lubrication.
