Foundations of Nursing - Exam 3

breast subjective data

• pain, lump, and discharge

• rash, swelling, trauma

• history of breast disease

• surgery or radiation

• medications

• mammogram

• self breast examination

SBE

self breast examination

breast subjective data

• pain, lump, and discharge

• rash, swelling, trauma

• history of breast disease

• surgery or radiation

• medications

• mammogram

• self breast examination

SBE

self breast examination

45 to 50

annual mammography should be performed at from ages _____ to _____

55

biannual mammography or continuation of annual mammography should be performed over age _____

breast cancer

_______ ______ is the 2nd major cause of death from cancer in women

99%

what is the 5 year survival rate of breast cancer in the US today?

85%

what is the 5 year survival rate of breast cancer in the US today, if spread regionally?

relative risk

RR, if RR > 1 there is an indication of a higher likelihood of an occurrence among exposed then unexposed persons

nipples

these usually protrude although some are flat or inverted

supernumerary nipple

• also known as extra nipples

• common minor birth defect where a person has one or more nipples in addition to their normal two

• typically harmless and often unnoticed until puberty or hormonal changes cause them to become more noticeable

lymph nodes

these can be found in the axillae but should be non palpable, if they are palpable, they should be small, soft, and nontender

circular method

examine the breast starting at the nipple and moving in a circular motion outwards

wedge method

examine the breast starting at the nipple and dividing the breast into wedges or pizza slices and feeling each wedge using a systemic approach

vertical strip method

examine the breasts starting at one side of the breast moving in an up and down moving moving your way across the breast to the opposite side

ask, advise, assess, assist, arrange

5 A’s counseling method (smoking)

3

the right lung has ___ lobes

2

the left lung has ___ lobes

vesicular lung sounds

• normal lung sounds

• soft, low-pitched, rustling sounds

• heard during inspiration and fade quickly during expiration

• indicate that the airways are clear and free from obstruction or inflammation

bronchovesicular lung sounds

• normal lung sounds

• medium pitch

• heard during both inhalation and exhalation

• considered intermediate between bronchial and vesicular sounds

• typically located in the mid-chest area and posterior chest between the scapulae

• reflect a mixture of bronchial and vesicular components, with equal inspiratory and expiratory phases.

bronchial lung sounds

• loud, high-pitched, and hollow sounds

• heard over the large airways, particularly the trachea and bronchi, when auscultating the chest

• normal over these areas but can be abnormal if heard in other lung regions

• characterized by a distinct pause between inspiration and expiration, and the expiratory phase is typically longer than the inspiratory phase

crackles, wheezes, rhonchi

3 examples of adventitious breath sounds

fine crackles

• high pitched, soft, brief crackling sounds

• can be stimulated by rolling a strand of hair near the ear or stethoscope

course crackles

• low pitched, moist longer crackling sounds

• sounds similar to velcro be separated slowly

wheezing

• high pitched musical sounds heard primarily during inspiration

• may be audible in severe asthma or bronchitis

• sputum color - clear

rhonchi

• low pitched snoring or gurgling sound

• may clear with coughing

pleural friction rub

• loud, course, and low pitched grating or creaking sound

• similar to a squeaky door opening

• heard during inspiration and expiration

TRIPOD position

commonly found in people experiencing respiratory distress, ex. COPD

tachypnea

breathing greater than 24 breaths per minute

bradypnea

breathing less than 10 breaths per minute

stridor

a loud, high-pitched crowing or honking sound (seal) from the upper airway - EMERGENCY

chronic hypoxia

clubbing indicates…

barrel chest

the term that coins a 1:1 anteroposterior and lateral diameter of thorax, common in COPD patients

S1

• sound heard best at the apex (bottom) of the heart

• occurs with the closure of the AV valves

• signals the beginning of systole

S2

• sound heard best at the base (top) of the heart

• occurs with the closure of the semilunar valves

• signals the end of systole

• aortic component slightly precedes pulmonic component

S3

• can be common in patients with heart failure or high BP

• occurs when ventricles are resistant to filling during early rapid filling phase

• occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles

S4

• commonly found in patients with thickening of the heart tissue

• occurs at the end of diastole, at presystole, when the ventricles are resistant to filling

• this occurs just before S1

heart murmur

• an abnormal sound as a result of turbulent blood flow, often due to valve dysfunction or other cardiac anomalies

• described as a gentle, blowing or swooshing sound that can be heard on the chest wall

• can be a result of increased blood velocity or viscosity or valve structural defects

dyspnea

shortness of breath

angina

chest pain

orthopnea

short of breath when laying down

fluid overload or right sided heart failure

jugular venous distention may be a possible indication of this

aortic

2nd intercostal space, right sternal border

pulmonic

2nd intercostal space, left sternal border

erb’s point

3rd intercostal space, left sternal border

tricuspid

4th intercostal space, left sternal border

mitral

5th intercostal space, mid clavicular line

heart disease

this is the leading cause of death in both men and women worldwide

peripheral arterial disease

• PAD

• affects non coronary vessels and refers to arteries affecting the limbs

• leads to reduced blood flow limiting oxygen in tissues

• smoking, age, obesity, and diabetes are all risk factors

lymphatics

a separate vessel system which retrieves excess fluid and plasma proteins from the interstitial spaces and returns it to the bloodstream

small, soft, mobile, nontender

what are considered normal findings of lymph nodes?

enlarged lymph nodes

• also called lymphadenopathy

• nodes larger than 1 cm

• may be tender, hard, or fixed

• may indicated infection, inflammation, or malignancy

tender nodes

• finding in lymph nodes that usually indicates infection or inflammation in the region that the node drains

hard/fixed nodes

• finding that may indicate lymph node malignancy

generalized lymphadenopathy

• enlargement of lymph nodes in multiple areas

• can indicate a systemic infection, autoimmune diseases, or cancers like lymphoma

spleen

• located in the upper left quadrant of the abdomen

• destroys old red blood cells

• produces antibodies

• stores red blood cells

• filters microorganisms from blood

tonsils

• includes palatine, adenoid, and linguil

• located at the entrance to the respiratory and gastrointestinal tracts

• responds to local inflammation

thymus

• flat, pink-grey gland located in the superior mediastinum behind the sternum and in front of the aorta

• responsible for T-cells

pitting edema scale

+1 - 2mm depth

+2 - 4mm depth

+3 - 6mm depth

+4 - 8mm depth

dysphagia

difficulty swallowing

pica

ingestion of non-food items…includes ice, toilet paper, drywall, ashes

constipation

• this is not a physiological consequence of aging

• can be cause by several factors: decreased physical activity, dehydration, low fiber diet, medication side effects, bowel obstruction, hypothyroidism, difficulty ambulating to toilet

contour, symmetry, umbilicus, skin

key components to look at when inspecting the abdomen

inspection, auscultation, percussion, palpation

order of abdominal assessment

begin in the RLQ

when auscultating for bowel sounds in the abdomen…

normal bowel sounds

5-30 per minute

hypoactive bowel sounds

< 5 gurgles per minute

hyperactive bowel sounds

> 30 gurgles per minute

borborygmus

the name for the sound of stomach growling (hyperperistalsis)

absent

you must listen for 5 minutes in every quadrant to determine if the bowel sounds are _______

CVA

• costovertebral angle tenderness

• positive finding indicates inflammation of the kidney

• to assess, place one hand over the 12th rib and hit that hand with your fist, repeat with the other side

light palpation of abdomen

• use 4 fingers

• depress skin about 1 cm

• make a gentle rotary motion, moving clockwise

deep palpation of abdomen

• use 2 hands

• depress skin 5-8 cm (2-3 in)

• used to detect masses or abnormal organ sizes

ascites

buildup of fluid in the abdomen

osteoporosis screenings

• this is important for post-menopausal women

• remind them to also focus on implementing weight bearing exercises

inspection, palpation, range of motion

order of musculoskeletal assessment

GALS assessment

• locomotor screening

• assesses gait, arms, legs, and spine

• patient performs 11 tasks and the examiner asks two questions…do you have any pain or stiffness anywhere? do you have any difficulty washing, dressing, or climbing stairs?

lordosis

exaggerated inward curve of lumbar spine

scoliosis

lateral/sideways curve of the spine

kyphosis

enhanced curvature of the thoracic spine, “humpback“

ankylosis

abnormal stiffness of a joint due to the fusion of bone, occurs in severe cases of rheumatoid arthritis

contractures

permanent tightening of muscles, tendons, ligaments, or skin that restricts movement and/or felxibility

bursitis

inflammation of a bursa, a small fluid-filled sac that reduces friction between muscles or bones…prominent in shoulders, elbows, and hips

tendinitis

inflammation of a tendon due to overuse or injury

osteoarthritis

• also called degenerative joint disease

• the pain worsens with activity and improves with rest

• can have hard, bony protrusions

• limited ROM

rheumatoid arthritis

• symmetrical joint involvement

• common on the hands and feet

• pain is worse in the morning

carpal tunnel

• pain in the wrists

• can cause finger numbness and tingling

• caused by lots of repetitive movement

acute gout

• crystals caught in joint

• due to increased levels of uric acid in the blood

• dietary restrictions are helpful in alleviating symptoms

LOC

level of consciousness

glascow coma scale

• used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients

• assesses eye opening response, verbal response, and motor response

• desired score of 15

decorticate rigidity

• flexion in upper extremities

• extension and internal rotation in lower extremities

• **indicates hemispheric lesion…bleeding**

decerebrate rigidity

• stiffly extended upper extremities

• palms pronated

• flexed wrists

• stiffly extended lower extremities

• **indicates lesion in brainstem*

flaccid quadriplegia

• complete loss of muscle tone and paralysis of all four extremities

• indicating nonfunctional brainstem

opisthotonos

• prolonged arching of the back with head and heels bent backwards

• indicates meningeal irritation

AVPU

A - Alert and conscious

V - Responds to verbal stimulus

P - Responds to painful stimulus

U - Unresponsive to any form of stimulus

lethargic

drowsy, sluggish

obtunded

difficult to arouse

stuporous

requires rigorous stimulation

comatose

no response

gait

• this should be smooth, rhythmic, and effortless

• opposing arms should swing accordingly

• turns should be smooth

• step length should be about 15 inches from heel to heel

ataxia

unsteady/uncoordinated gait