NURS 222 Final Exam

TPR

temperature
pulse
resirations

when measuring pulse..always record

grade
rate
force/strength
equality bilaterally

BP

blood pressure

How to take BP

needed: cuff and stethoscope
2 step: 1. put cuff on patient
2. find radial pulse
3. pump until radial pulse is gone.
4. use that number and go up 30 from that
5. Use stethoscope to find brachial pulse
6. Pump up to the +30 number
7. slowly release pressure until you hear pulse sounds (this is systolic number)
8. keep slowly releasing pressure until no more pulsing is heard (this is diastolic number)
9. record

normal BP

120/80

normal pulse

55-95 bpm

normal respirations

10-20 breaths/min

orthostatic blood pressure

patient is supine for 3 mins, then take BP
sit up, and wait for 1-3 mins, then take BP
stand and wait for 1-3 mins, then take BP
variations should not show a drop of 20 mmHg in systolic or decrease of 10 mmHg in diastolic

systolic

occurs when ventricles are contracting; top number

diastolic

occurs when ventricles are relaxing; bottom number

factors influencing body temp

age
diurnal variations
exercise
hormones
stress
environmental temp/humidity
illness

factors affecting pulse rate

age
gender
activity/exercise
fever
emotions/stress
medications
blood loss
position changef

actors affecting respirations

age
exercise/activity
pain/stress
medications
altitude
smoking
body position

factors influencing BP variations

age
gender
race
diurnal
weight
exercise
emotions
stress
drugs
illness/condition
external environment
smoking
gender
ethnicity
diurnal variations

normal o2 saturation

95%-100%

BMI underweight

BMI healthy

18.5-25

BMI overweight

25.0-30

BMI obesity

>30

General appearance (general survey)

Physical appearance
--age
--sexual development (identify)
--level of consciousness-alertness
--skin color
--skin-intact, warm, even tones
--facial features-symmetrical and move symmetrically
-LOC

behavior (general survey)

facial expression-eye contact, appropriate for situation, conversation changes w/ topic
--mood/affect
--speech
--dress
--personal hygiene

body structure (general survey)

height
nutrition
symmetry
posture
position
body build
deformity

mobility (general survey)

gait
involuntary movements
ROM

measurements (general survey)

height
weight
BMI

skin examination (inspection)

color
general pigmentation
areas of hypopigmentation/hyperpigmentation
abnormal color changes

skin examination (palpation)

temperature
moisture
texture
edema
turgor
hygiene
vascularity/bruising

skin examination (lesions)

color
shape/configuration
size
location and distribution on body

skin examination (hair)

texture
distribution
scalp lesions

skin examination (nails)

shape and contour
consistency
color
capillary refill

skin turgor

measures hydration
tenting or immediate recoil

pitting edema

excess fluid in certain areas of the body
when applied pressure, a pit will form

confluent

lesions run togethera

annular/circular

begins in center and spreads to periphery

discrete

distinct, individual, lesions remain separate

gyrate

twisted, coiled, spiral

grouped

cluster of lesions

linear

target

resembles iris of eye, concentric rings of color in lesions, bullseye

Zosteriform

linear arrangement along a unilateral nerve route

polycyclic

annular lesions grow togethers

strabismus

crossed eyes
eyes don't look in the same direction at the same time

presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occuring in middle/old age

diplopia

double vision

floaters

happen because of normal changes in eyes
tiny strands of vitreous that cast shadows and appear as floaters

aniscoria

unequal pupil sizes

ear examination

1.inspect external ear
2. otoscopic examination
3. tympanic membrane inspection
4. hearing acuity

tympanic membrane

pearly gray color
shiny
translucent
cone of light @ 7:00 in L ear
cone of light @ 5:00 in R ear

vesicular breath sounds

heard over clavicles and peripheral and lateral lung fields
inspiration is louder than expiration

brochial breath sounds

heard over and around the trachea
exhalation longer than inhalation

bronchovesicular breath sounds

heard over main bronchi anteriorly and posteriorly
exhalation and inhalation

murmur

a whooshing or rapid, turbulent blood flow

thrill

palpable murmur

apical impulse

gentle tap and is small in amplitude and corresponds to 1st 2/3 of systole

tachycardia

fast heart rate

bradycardia

slow heart rate

layers of heart wall

epicardium
myocardium
endocardium

heave

abnormally large heart beat

crackles lung sound

fluid in lungs

wheezing lung sound

almost musical sound
shrill whistle
coarse rattle

ronchi lung sound

continuous gurgling or bubbling sound

stridor lung sound

high pitched squeaking or whistling

pleural friction rub

audible raspy breathing sound
leather rub

Aortic Area

2nd intercostal space
R sternal border
S2 is louder than S1

Pulmonic Area

2nd intercostal space
L sternal border
S2 is louder than S1

Erb's Point

3rd intercostal space
L sternal border
S2 equal to S1

Tricuspid Area

4th intercostal space
L sternal border
S1 louder than S2

Mitral (apical area)

5th intercostal space
Midclavicular line
S1 louder than S2

valves of the heart

Aortic
pulmonic
tricuspid
bicuspid

vertigo

spinning

peripheral vertigo

dizziness
can still walk

central vertigo

dizziness
severe instability

Correct order for completing an abdominal assessment

inspection
auscultation
percussion
palpation

Assess for kidney inflammation

CVA tenderness

contours of the abdomen

flat
scaphoid
rounded
protuberant

aging adult GI differences

increased subcutaneous fat
abdominal musculature is thinner
organs easy to palpate
liver easier to palpate