Medical-Surgical Nursing Review

Flashcards related to Heart, Neck Vessels, Peripheral Vascular, Lymphatic, Musculoskeletal, and Neurological Systems.

Pericardium

The outer layer of the heart.

Myocardium

The middle layer of the heart.

Endocardium

The inner layer of the heart.

RA

Right atrium of the heart.

RV

Right ventricle of the heart.

LA

Left atrium of the heart.

LV

Left ventricle of the heart.

Atria

Thin walled structures that act as reservoirs; they receive blood from the lungs and body.

Ventricles

Larger, thicker chambers that pump blood to the body and lungs.

Atrioventricular Valves

Valves located between the atrium and ventricle: tricuspid (right) and mitral (left).

Semilunar Valves

Valves that include the pulmonic valve, which separates the RV from the pulmonary artery, and the aortic valve, which separates the LV from the aorta.

Functions of Valves

They separate the atria and ventricles, allow blood flow, and prevent backflow.

S1

The sound produced by the closure of the AV valve (loudest at the apex) at the 5th intercostal space.

S2

The sound produced by the closure of the semilunar valves (loudest at the base, 2nd intercostal space, right sternal border).

Diastole

The phase when the cardiac muscle relaxes; the ventricles fill.

Systole

The phase when the cardiac muscle contracts; blood is ejected out of the heart into the arteries.

SA Node

The sinoatrial node, known as the pacemaker of the heart.

Electrocardiogram (EKG)

A test that detects the action potentials of SA nodal and myocardial cells.

Cardiac Output

The volume of blood pumped out of the heart each minute, calculated as stroke volume multiplied by heart rate.

Preload

The volume left in the chamber at the end of diastole (stretching).

Afterload

The force opposing ventricular ejection (resistance or blood pressure).

Arteries

Vessels that carry oxygenated blood from the heart to the rest of the body.

Veins

Vessels that drain deoxygenated blood and waste products from tissues and return it to the heart.

Intermittent Claudication

Leg cramping.

Paresthesias

Numbness and tingling.

Poikilothermia

Inability to regulate core temperature.

Pronation

The rotation of the hand or forearm so that the palm faces downward or toward the back.

Myalgia

Muscle pain (cramping or aching); viral illness can cause myalgia.

Arthralgia

Joint pain.

Rheumatoid Arthritis - Inflammatory Conditions

A condition characterized by inflammation of joints leading to swelling and stiffness.

Ankylosing Spondylitis - Inflammatory Conditions

A condition that causes the spinal vertebrae to fuse (affecting the lower back).

Osteoarthritis – Degenerative Condition

A type of arthritis affecting any joint; pain worsens with movement.

Osteoporosis - Degenerative Condition

A condition where bones are fragile and prone to breaking.

CNS

The central nervous system, consisting of the brain and spinal cord.

PNS

The peripheral nervous system, comprising 12 pairs of cranial nerves and 31 pairs of spinal nerves; it sends sensory messages to the CNS and receives motor messages from the CNS.

Frontal Lobe

The region responsible for personality, behavior, intellect, and emotions.

Parietal Lobe

The region associated with sensations.

Occipital Lobe

The region related to vision.

Temporal Lobe

The region associated with auditory perception, taste, and smell.

Cerebellum

The region responsible for equilibrium, coordination, and balance.

Basal Ganglia - Areas that Mediate Function

Regions involved in automatic movements.

Thalamus - Areas that Mediate Function

Regions responsible for sensory processing.

Hypothalamus - Areas that Mediate Function

Regions involved in the regulation of temperature, blood pressure, heart rate, autonomic nervous system, and emotions.

Brain Stem Core

Consists of the midbrain, pons, and medulla.

Spinal Cord

The structure that acts as a relay station for sensory and motor impulses.

Changes in Aging Adults

Includes muscular atrophy, changes in pupil shape, decreased pupillary reflexes, senile tremors, and unstable balance.

Syncope

Fainting due to cardiac or neurological issues (underlying illness).

Aphasia

Difficulty in speaking.

Visual Acuity - CN2

Vision is checked using the Snellen chart and near vision chart.

Confrontation - CN2

To assess peripheral vision, the patient looks straight ahead and indicates when they see fingers moving from behind to in front.

CN 3,4,6

Pupils are assessed for PERRLA (pupils equal, round, reactive to light and accommodation), along with the 6 cardinal gazes.

CN 5 - Trigeminal Nerve

Assess the patient’s ability to open their mouth; assess for pain; lightly touch the face with an object and ask if it is sharp or dull.

CN 7 - Facial Nerve

Assess for symmetry by asking the patient to smile and puff their cheeks.

CN 8 - Acoustic Nerve

Hearing is tested using the whisper test.

CN 9,10,12 – Glossopharyngeal, Vagus, Hypoglossal Nerves

To assess, ask the patient to say 'ah'; check the uvula; assess gag reflex with a tongue depressor; check that the tongue is midline.

CN 11 - Spinal Accessory Nerve

To assess the trapezius muscle, ask the patient to shrug their shoulders against resistance; assess the sternomastoid muscle by having the patient turn their head against resistance.

Stereognosis

The ability to recognize objects by touch with eyes closed.

Graphesthesia

The ability to identify numbers or letters drawn on the hand with eyes closed.

Glasgow Scale Less Than 8 Intubate

Indicates a need for intubation.

Erectile Tissue Layers

Comprising two corpora cavernosa and one corpus spongiosum.

Scrotum

The loose protective sac that contains the testicles.

Cremaster Muscle

Regulates scrotal temperature and the size of the scrotum (maintains at 3 degrees below abdominal temperature).

Inguinal Canal

Contains the internal and external rings; it carries a risk of hernia (loop of bowel protruding through weak muscle).

Dysuria

Pain or burning sensation during urination.

Hesitancy/Straining

Difficulty starting urination or forceful dribbling (common in benign prostatic hyperplasia).

Lumps in Scrotum

Should feel rubbery.

Epididymitis

Inflammation of the epididymis.

Spermatic Cord Varicocele

An abnormal enlargement and twisting of veins in the spermatic cord, similar to varicose veins.

Spermatocele

An abnormal sac that develops on the epididymis.

Orchitis

Inflammation of the testicle.

PAP Test

A screening test for cervical cancer, recommended for premenopausal women aged 35 to 45.

Menstrual History

Assessment of the date of the last menstrual period, age of first menstruation, and length of menstrual cycles.

G - GRAVIDA

A term indicating a woman who is pregnant.

P - PARA

A term indicating the number of births a woman has had after 20 weeks of gestation.

T - TERM

Refers to babies born after 37 weeks of gestation.

P - PRETERM

Refers to babies born before 37 weeks of gestation.

A - ABORTION

The loss of a pregnancy.

L - LIVING

The number of living children.

Inspection of External Genitalia

Assessment of skin color, hair distribution, labia majora, lesions, and clitoris.

Papanicolaou (PAP) Test

A test used for screening cervical cancer.

Urethritis

Inflammation of the urethra.

Breast

Located between the 2nd and 6th ribs, extending from the side of the sternum to the midaxillary line.

Axillary Tail of Spence

The superior corner of breast tissue that extends into the axilla.

Montgomery Glands

Glands that secrete lipid material during lactation.

Cooper’s Ligaments

Fibrous bands that support breast tissue.

Upper Outer Quadrant of the Breast

The area that is most commonly associated with breast tumors.

Aging Women after Menopause

Characterized by decreased hormone production and tissue atrophy.

Rash

To assess, inquire about when and where the rash started on the skin.

Surgery

Inquiry about any breast surgeries the patient has had and any X-ray screenings.

Swelling

Inquiry about localization and relation to menstruation or pregnancy, and changes in bra size.

Examine Axilla

Assessment of beauty (breast implants) and emotional state along with tenderness, lumps, swelling, or rash.

Gynecomastia

A temporary condition in males characterized by enlarged breast tissue.

Pay Attention to Behavioral Cues and if Patients Deny Pain

Crucial observations during the general survey of older adults.

Body Contour

Assessment of sharpness in posture, gait base, weight (loss and fat deposits), and height.

Fever

A potential indicator of underlying issues.

Inquire with Patient About Any Noticeable Skin Changes

Includes delayed wound healing, skin pains, and conditions such as diabetes that may lead to dry and itchy skin, and peripheral vascular disease (PVD).

Skin Tags

Commonly found in obese patients.

Clavicle Assessment

A careful check on the clavicle is advised as elderly patients may have decreased turgor leading to skewed results.

Ptosis

Refers to droopy eyelids and observation of external eye structures.

Cataract Patients

This group typically experiences vision problems.