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Nursing 2104 Midterm
Nursing Process and Health Assessment Midterm
95
Nursing
Undergraduate 2
10/27/2011

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Cards

Term
OLD CART
Definition
onset, location, duration
character, aggravating/alleviating symptoms, relevant family history, treatment
Term
What are the techniques of Physical Examination?
Definition
IPPA- Inspect, Percuss, Palpate, Auscultate
Term
In what orde should an abdominal examination be done? Why?
Definition
Inspect, Auscultate, Percuss, Palpate
Palpating can be sensitive and if the person if having an abdominal problem you don't want to further aggravate it before checking everything else
Term
Define Skin Turgor
Definition
elasticity of skin
Term
How does skin change with age?
Definition
It becomes thinner, and less elastic
Term
What are the ABCDs of Malignant Melanoma
Definition
Assymetry, Border, Color, Diameter
Term
What is clubbing?
Definition
when the nails are concave instead of convex
Term
What causes clubbing
Definition
Hypoxia due to lack of oxygen in the nails
Term
Jaundice
Definition
yellowing of the skin due to a decrease of liver function and excess of bilrubin
Term
Pallor
Definition
white or paleness of the skin due to lack a blood flow
Term
Alopecia
Definition
Hair loss
Term
Hirsutism
Definition
Excess hair
Term
Erythema
Definition
Redness of the skin due to excess blood flow
Term
Vitiligo
Definition
Irregular white patches of skin
Term
Papule
Definition
elevated,firm,circumscribed area less than 1 cm in diameter (wart, elevated mole)
Term
Macule
Definition
flat, circumscribed, colored lesion (freckles)
Term
Plaque
Definition
large portion of the skin with colored lesions (psoriasis)
Term
Nodule
Definition
more elevated than a papule
Term
Bulla
Definition
fluid filled blister of the skin
Term
Telangiectasia
Definition
small dialated blood vessels near the surface of the skin or the mucous membranes, measuring between 0.5 and 1 millimeter in diameter
Term
Petechiae Pustule
Definition
little blod clots beneath the skin (intravascular defects, infection)
Term
Vesicle
Definition
elevated, circumscribed, superficial, filed with serous fluid (chicken pox)
Term
Urticaria
Definition
Hives
Term
Pruritis
Definition
Itchy
Term
Excoriation
Definition
an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn
Term
Ecchymosis
Definition
red-purple nonblanchable discoloration of variable size (bruise)
Term
Wheal
Definition
pruritis uticaria (itching hives) on the skin commonly as a result of an allergy
Term
Lymph nodes
Definition
pre-auricular, post auricular, submental,occipital, paratid, sunmadibular,deep cervical chain, supraclavicular
Term
What do you look for in the thyroid?
Definition
size, shape symmetry, tenderness, nodules
Term
Cartoid Pulse
Definition
neck pulse
Term
Bruit
Definition
high blood flow through the thyroid
Term
Adams Apple
Definition
thyroid cartilage
Term
Where are the tonsils?
Definition
behind the uvula on either side of the throat
Term
How do you check for a gag reflux?
Definition
touch the tongue depressor to the back of the throat
Term
What cranial nerves are involved in gag reflex?
Definition
Cranial nerves IX and X
Term
What is stenson's duct?
Definition
parotid ducts; takes saliva from parotid gland into mouth
Term
Salivary ducts
Definition
under the tongue and above the top teeth in the back of the mouth
Term
Where are the sinuses?
Definition
On either side of the nose (maxillary), between the eyes (Sphenoid and Ethmoid Sinuses) and between the eyebrows (frontal sinuses)
Term
Where are the frontal sinuses?
Definition
Between the eyebrows
Term
Where are the maxillary sinuses?
Definition
On either side of the nose
Term
Where are the Sphenoid and Ethmoid Sinuses?
Definition
between the eyes
Term
Name the sinuses?
Definition
Maxillary, Sphenoid, Ethmoid, and Frontal
Term
How do you examine sinuses?
Definition
Inspect and palpate, look for swelling, tenderness, and transillumination
Term
What does cranial nerve V and VII control?
Definition
V: Trigeminal: sensation of face and chewing muscles

VII: Facial: Facial expressions
Term
Cranial Nerve I
Definition
Olfactory: smell
Term
What does Epitaxis mean?
Definition
nosebleed
Term
How do you check vision on a physical exam?
Definition
snellen or E chart, one eye at a time
Term
What does 20/20 mean?
Definition
You see letters from 20 feet away as is they are actually 20feet away, which is the standard for normal vision
Term
What are the EOMS
Definition
Test 6 Cardinal Fields of Gaze
Term
Which cranial nerves control the EOMS?
Definition
III- oculomotor
IV- trochlear
VI- Abducens
Term
Cataract
Definition
disease caused by excessive UV light exposure
Term
Glaucoma
Definition
disease caused by too much ocular pressure due to aqueous fluid accumulation
Term
Presbyopia
Definition
changes in sight due to aging
Term
Hordeolum
Definition
a sty, infection of the eye
Term
Chalazion
Definition
little bump, usually on the upper eyelid; a growth
Term
Myopia
Definition
Nearsightedness
Term
stabismus
Definition
one eye lagging behind the other; a "lazy eye"
Term
Nystagmus
Definition
oscillations when looking sideways; involuntary eye movement
Term
Diplopia
Definition
seeing double
Term
Exopthalmus
Definition
eye bugles out due to hyperthyroidism
Term
Conjunctivitis
Definition
swelling or irritation of the eye, red blood vessels visible
Term
Ptosis
Definition
only one eye opens fully
Term
What is Arcus Senilis?
Definition
a cholesterol lesion around the eye
Term
Xanthelasma
Definition
soft raised yellow plaque on the eye
Term
What does PERRLA mean?
Definition
Pupil, Equal, Round, Reactive to light, and Accommodation
Term
How do you check peripheral vision?
Definition
bring hands from outside the person vision in until the patient can see the object
Term
Where are tears formed and drained from the eye?
Definition
Lacrimal Gland
Term
How do you check hearing on a physical exam?
Definition
gross hearing test, whisper test, watch test
Term
How do you check the ear in an adult? A child?
Definition
Adult: lift auricle up and back, slightly away
Child: pull back and down
Term
what cranial nerve is involved in hearing?
Definition
VIII- vestibulocochlear
Term
What is Meniere's disease?
Definition
inner ear disorder associated with vertigo (dizziness), hearing loss, tinnitus (ringing in the ears)
Term
What are the 3 ossicles?
Definition
3 small bones in the ear; smallest bone sin the body
Malleus, Incus, Stapes
Term
How should a normal tympanic membrane look?
Definition
pearly gray, cone sof light reflection visible, concave
Term
Cerumen
Definition
Earwax
Term
Labyrinthitis
Definition
Dizziness caused by ear problems
Term
Otitis Ledia
Definition
effusion in middle ear; tympanic membrane is bulging; internal earache
Term
Otitis externa?
Definition
swimmer's ear- external ear/ ear canal tender, discharge from outer ear
Term
Breast palpation techniques
Definition
wedge sections (spokes), circular, strips
Term
4 Breast exam positions
Definition
arms at side, arms over head, hands at hips, hands at hips and leaning forwar
Term
What is the tail of spence?
Definition
extension of breast into axilla
Term
Where does breast cancer most often occur?
Definition
upper outer quadrant
Term
How do you describe and document a lump found in the breast?
Definition
location, size, shape, consistency, distincness, nipple, skin over lump, tenderness, lymphadenopathy
Term
Menarche
Definition
first menstrual cycle
Term
Where are the axillary nodes?
Definition
in the armpit
Term
Montgomery Tubules
Definition
a group of 12-15 sebaceous glands in the areola of the nipple; these secrete a small amount of milk and help to keep the skin healthy and the areola elastic
Term
When is the best time to do a self-breast exam?
Definition
a week after your period
Term
What is Gynecomastia?
Definition
Male breast enlargement
Term
What is peau d'orange?
Definition
puckering of the skin; like the skin of an orange
Term
What is a supernumary nipple?
Definition
Extra nipple
Term
How long should listen in each quadrant, when auscultating the abdomen?
Definition
1 minute per quadrant
Term
What are striae?
Definition
stretch marks
Term
Where should you listen for bruits?
Definition
Aorta, right/left renal artery, right/left illiac artery, right/left femoral artery

You will hear swooshing sound over an obstructed artery
Term
What sound is percussed over the liver vs. the stomach?
Definition
liver: dull
stomach: tympany
Term
What is borborygmi?
Definition
Hyperactive bowel sounds, rushing sounds, often occurs with diarrheal illness
Term
Melena
Definition
black feces that occur with gastrointestinal hemmorage
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