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Nursing Health Assessment Terminology
Note Cards for USM's NUR 300 (Total Health Assessment Class) with Nancy Baugh. Covers Chapters 13, 14, 15, 16, 18.
Terms in this set (189)
abnormal anterior-posterior curvature of the spine
sternum protruding from the chest
sternum sunken into the chest
chest wall increased anterior-posterior; ribs horizontal, costal angle > 90 degrees. normal in children; typical of hyperinflation seen in COPD
abnormal lateral curvature of the spine
which is alternating breathing in high frequency and low frequency from brain stem injury.
An acidotic patient will have more rapid breathing to compensate.
Top of Lungs
Bottom of Lung
Percussion of Lungs with dullness indicates
Consolidation (mass or fluid filled)
Percussion of Lungs with hyper-resonance indicates
abnormal collection of air or gas (Pneumothorax)
Percussion of Lungs with resonace indicates
describing a continuous musical sound on expiration or inspiration. Result of narrowed airways. Common causes include asthma and emphysema
low pitched, musical bubbly sounds heard on inspiration and expiration. Fluid in the airways.
Crackles or rales.
Intermittent, non-musical and brief sounds heard during inspiration only. They may be described as fine (soft, high-pitched) or coarse (louder, low-pitched). These are the result of alveoli opening due to increased air pressure during inspiration. Common causes include congestive heart failure.
a high-pitched musical breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. Causes are typically obstructive, including foreign bodies, croup, epiglottitis, tumours, infection and anaphylaxis.
Normal diaphragmatic excursion
3 to 5 cm.
Right Lung Lobes
RUL, RML, RLL
Left Lung Lobes
What is Whispered pectoriloquy
spoken sounds of a whispered volume by the patient would not be heard by the clinician auscultating a lung field with a stethoscope
Whispered pectoriloquy; abnormal
words are heard, means consolidation (fluid or mass)
Normal Adult Respirations
12 - 20
What increase respirations
Anxiety, Pain, Painic Attacks, Excerise, labor
what decreases respirations
medications, obstruction, sleep
Increased respirtaorty rate
Is inhalation passive or active?
Is expiration passive or active?
What is Tactile Fremitus
assessment of the lungs by either the vibration intensity felt on the chest wall
Decreased Tactile Fremitus means
abnormal collection of air or gas (Pneumothorax)
Increased Tactile Fremitus means
consolidation (masses or fluid)
occur when the muscles between the ribs pull inward. The movement is most often a sign that the person has a breathing problem.
How many ribs
u shape depression above the sternum
when your thoracic cage meets at the xiphoid process, making a upside down V. Flatens out in COPD
What is Symmetric expansion
hands placed at t9 or t10, when patient breaths you look for equal movement
Palpable with thick bronchial secretions
Pleural Friction Fremitus
palpable with inflammation of the pleura
coarse, crackling snesations felt over the skin surface. (air escaping lungs and pocketing in subcutaneous tissue)
What is Diaphragmatic excursion
is the movement of the thoracic diaphragm during breathing.
What is Abormal Diaphragmatic excursion
less than 3-5 cm the patient may have a pneumonia or a pneumothorax
Normal, high pitched, loud, more in expiration, harsh and hollow, trachea and larynx
Normal, Moderate pitched, moderate in sound, equal in inhalation and expiration, over lungs
Normal, Low pitched, soft, greater in inhalation, rustling, on edges of lungs
Decreased or Absent breath sounds means
no air is moving in or out!
Increased Breath sounds means
louder, high pitched, pro-longed expiration, with pasue bewtween inhalation and expiration. Sounds very close to stethoscope. Common in consolidation.
Forced expiratory time
ask patient to inhale big breath and blow out as quickly as possiable, listen with your stethocsope over sternum. Normal time is 4 sec or less
What is Bronchophony?
when you ask the patient to repeat "ninety-nine" while you listen with a stethoscope; Should hear sound through the stethoscope but not be able to distinguish the words "ninety-nine".
What is Egophony?
when you auscultate the chest while the person phonates a long "ee-ee-ee" sound; should hear "eeeee" through your stethoscope.
Abnormal Forced expiratory time
6 seconds or more indicates obstructive lung disease.
Forced vital capacity (FVC)
This measures the amount of air you can exhale with force after you inhale as deeply as possible.
Total lung capacity (TLC)
This measures the amount of air in your lungs after you inhale as deeply as possible.
Residual volume (RV)
This measures the amount of air in your lungs after you have exhaled completely. It can be done by breathing in helium or nitrogen gas and seeing how much is exhaled.
Functional residual capacity (FRC)
This measures the amount of air in your lungs at the end of a normal exhaled breath.
what the nasal cavityis divided by
on the lateral walls of each nasal cavity they are three parallel bony projections
Cleft underneath each bony projection
frontal bone aboue and medial to the orbits
on maxilla along side the nasal cavity
roof of mouth, front portion
roof of mouth, back portion
free projection hanging down from the middle of the soft plate
midline fold of tissue that connects the tongue to the mouth
lies with in the cheeks in front of the ear and extends down to the jaw. It's duct is the stensen's duct.
located on the buccaa muscosa opposite of molars
lies beneth the mandible, it's duct is the whartons duct
located on eith side of the frenulum
what is the otoscope used for
looking in your nose and ears!
What should normal nasal mucosa look like
red, smooth, moist
What should abnormal nasal mucosa look like
swelling, blood, discharge, foreign body
Deviated septum is what
a condition in which the nasal septum -- the bone and cartilage that divide the nasal cavity of the nose in half -- is significantly off center, or crooked, making breathing difficult.
what does a deviated septum look like
a hump or shelf in one nasal cavity
what is perforated septum
An abnormal opening in the septum
what does perforation look like
a spot of light from a penlight shining into the other naris
small, isolated white/yellow papules on the mucosa of the cheek, otngue and lips. painless and not significant
Tonsil graded as a 1+ is
Tonsil graded as a 2+ is
halfway between tonsillar pillars and uvula
Tonsil graded as a 3+ is
touching the uvula
Tonsil graded as a 4+ is
touching each other
What is a normal tonsil grade
1+ or 2+
small boil located in the nasal cavity. looks red, swollen and painfull
What does Rhinorrhea looks like?
swollen mucosea and red, swollen turbinates
What does Gingivitis look like?
gums are swollen, red, and bleed easy.
What does leukoplakia look like?
raised, thick, white chalky patches that cant be scraped off. precanerous
What does candidiasis (thrush) look like?
white, cheesy, curd like patchs on the buccal mucosa or/and tongue. Can be scraped off, leaving area looking raw.
What does a Abscessed tooth look like?
Redness and swelling of the gums, Swollen area of the upper or lower jaw, An open, draining sore on the side of the gum
Where is the Temporal Artery?
side of face, in bewteen eyes and infront of ears.
Where is Temperomandibular joint?
Jaw joint, side of face, below ears.
Transillumination of Sinuses
A techinque that uses light to see if there is sinus inflammation by symmetry of lights illumination in nares, no evidence to support this practice.
What is Chelitis?
inflammation of the lips, scaling, erythema, shallow and painful fissures
What does squamous cell moth cancer look like?
may appear as white or red patches rather than sores or lumps. Smokers may have a brown, freckle-like area on the lip instead. The most common sign is an open sore that does not heal. These sores, or ulcers, erode into underlying tissues and bleed intermittently. Growths may be white or red and may be smooth or raised. If a lump forms, it will be hard and immovable, unlike benign lumps that move freely.
painless inlargment of the gums
bony ridges down the middle on the hard plate
What does black hair tongue look like?
pain less overgrowth of mycelial threads of fungal infection. Black, brown yellow patches on tongue. Related to use of antibotics
What does geographic tongue look like?
pattern of normal coating interspread with bright red, shiny, circulat bald areas with pearly borders. Not significant
What does atrophic glossitis look like?
tongue is smooth, glossy, shiney and slick. mucosa thins and looks red. tongue dryness and burning.
Patient breath smells like acetone; indicates what?
This is a characteristic sign of ketosis and ketoacidosis- metabolic problems which may occur in diabetes. Ketosis results from large scale conversion of fats into fatty acids and ketone bodies when glucose metabolism is impaired (either by diet or disease). Ketoacidosis results when ketosis is accompanied by a drop in the pH of the blood, and is a potentially life-threatening condition
Patient breath smells like ammonia; indicates what?
kidney problems (uremia)
What is allergic salute?
is the characteristic and sometimes habitual gesture of wiping and/or rubbing the nose in an upwards or transverse manner with the fingers, palm, or back of the hand. Often seen in people with allergic rhinitis.
Yellow staining of the theeth in a older adult is normal. T/F
The buccal mucosa in a older adult is thiner. T/F
Receding gums in a older adult is a abonormal finding. T/F
Dry mouth in a older adult is a abonormal finding. T/F
Losing a sense of taste is part of normal aging. T/F
difficulty in swallowing
neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. The movements may resemble a tremor.
The anterior chest contains mostly?
upper and middle lobe with very little lobe.
The posterior chest contains mostly?
all lower lobe.
Four major functions of respiratory system:
1) supplying oxygen to the body for energy production
2) removing carbon dioxide as a waste product of energy reactions
3) maintaining homeostasis of arterial blood
4) maintaining heat exchange
increase carbon dioxide in the blood
decrease in oxygen in the blood
In the aging adult costal cartilage become calcified. T/F
In older adults respiratory muscle strength doesn't decline. T/F
Patents with COPD often sit how?
Like a tripod, leaning forward with their arms braced on their knees.
Unequal Symmetric expansion of the thorax means what?
possible atelectasis (collapse of a lung or lobe), lobar pneumonia, pleural effusion, thoracic trauma (fractured ribs etc)
the "eeeee" sound turning into a "aaaaa" sound; happens in consolidation or compression.
When you can clearly hear "99"; happens in consolidation
Does residual volume in older adults increase or decrease?
a condition in which the body or a region of the body is deprived of adequate oxygen supply
The two major neck muscles
The Sternomastoid muscle divides each side of the neck into two triangles
1) anterior triangle
2) posterior triangle
Where is the Thyroid gland located
straddles the trachea in the middle of the neck
Where is the Hyoid bone?
High in the neck, below the the floor of the mouth
Where is the Thyroid cartilage?
is above the thyroid gland, below the hyoid bone
Where is the trachea?
in-between the clavicles and rest ontop of the manubrium
How many neck lymph nodes?
Where is preauricular lymph node located?
in front of the ear
Where is posterior auricular lymph node located?
behind the ear, superficial to the mastoid process
Where is occipital lymph node located?
at the base of the skull
Where is submental lymph node located?
midline, behind the tip of the mandible
Where is submandibular lymph node located?
halfway between the angle and the tip of the mandible
Where is jugulodigastric lymph node located?
under the angle of the mandible
Where is superficial cervical lymph node located?
overlying the sternomastoid muscle
Where is deep cervical chain lymph node located?
deep under the sternomastoid muscle
Where is posterior cervical lymph node located?
in the posterior triangle along the edge of the trapezius muscle
Where is supraclavicular lymph node located?
just above and behind the clavicle, at the steromastiod muscle
In pregnant women it is come for the thyroid to do what?
It is normal for older adults to have subcutaneous fat loss in their face?
Skin in older adults tend to be more moist or more dry?
What is Normocephalic?
Term used to described a normal, round, symmterical skull
What is microcephaly?
abnormaly small head
What is macrocephaly?
abnormaly large head
What is abnormal finding in the temporal artery?
feels hard, tender, crepitation, tortuous
What is abnormal finding in the lymph nodes?
swollen, tenderness, warm, hard, fixed
Tracheal Shift; normal findings
should be midline, slip to both sides; symmetrically.
Tracheal Shift; abnormal findings
Not at midline, does not slip to both sides; symmetrically.
What is thyroid bruit?
a abnormal sound heard with a stethoscope.; soft, pulsatile, whooshing, blowing.
In older adults the temporal arteries my be twisted. Is this normal or abnormal?
What is Acromegaly?
Excessive secretion of growth hormone from the pituitary gland after puberty creates an enlarges skull and thickened cranial bones.
What does a Enlarged Parotid Gland look like
swelling in the parotid gland (front of ear lobe)
A hematoma in one sternomastiod muscle, probably injured by intrauterine malposition. Results in head tilt to one side and limited neck ROM.
Temporomandibular joint; abnormal findings.
refers to lymph nodes which are abnormal in size, number or consistency and is often used as a synonym for swollen or enlarged lymph nodes.
What is the Snellen Eye Chart
alphabet chart used to measure visual acuity.
How far should the patient be from the Snellen Eye Chart
Near vision should start being tested in what age?
older than 40
What is the confrontation test
gross measure of the peripheral vision
how far away from your patient should you be when you do the confrontation test
What are the normal results of the confrontation test
50 degrees upward
90 degrees temporally
60 degrees nasally
What is the Corneal light reflex
Assess the parallel alignment of the eye axes
What is a normal finding when doing the Corneal light reflex
the reflected light on the corneas being the same
How far away should you be when you do the Corneal light reflex
What is the cover test
this test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel.
What is normal cover test findings
both eyes looking at same area, no lazy eye
what is the diagnostic positions test
when you lead the eye through six positions looking for muscle weakness during movement
what is abnormal findings in diagnostic positions test look like
eye movement not parallel, or eye twitching occurring
Nearsightedness, distant objects are blurred due to images focusing in front of the retina.
Farsightedness, where near objects are blurry due to light focusing behind the retina.
Age related inability to focus sharply on nearby objects due to a loss of elasticity of the crystalline lens.
A visual defect in which one eye cannot focus with the other on an object because of imbalance of the eye muscles. Also called squint.
A rapid, involuntary, oscillatory motion of the eyeball
Bleeding into the interior chamber of the eye.
the soft brownish-yellow wax secreted by glands in the auditory canal of the external ear Nontechnical name earwax
a progressive bilateral symmetrical age-related sensorineural hearing loss. The hearing loss is most marked at higher frequencies
Having a toxic effect on the structures of the ear, especially on its nerve supply.
a sensation of dizziness or abnormal motion resulting from a disorder of the sense of balance
A sound in one ear or both ears, such as buzzing, ringing, or whistling, occurring without an external stimulus and usually caused by a specific condition, such as an ear infection, the use of certain drugs, a blocked auditory tube or canal, or a head injury.
Pain in the ear; earache.
Inflammation of the pharynx, often a result of viral or bacterial infection, especially streptococcal bacteria.
loss of the sense of smell, usually as the result of a lesion of the olfactory nerve, disease in another organ or part, or obstruction of the nasal passages.
Bulging of the eye
Pupil dilation (can be result of anasthesia use)
Pupil constriction (can be result of narcotic use)
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