1. What is conjunctiva?
    the bulbar conjunctiva covers the exposed surface of the eyeball up to the outer edge of the cornea.
  2. What is sclera?
    Under the bulbar conjunctiva, has the color of white porcelain in whites and light yellow in dark-skinned clients. The whites of the eye which is fibrous and protective
  3. What are the lacrimal ducts?
    In the nasal corner or inner canthus of the eye, where tears flow to from the lacrimal gland
  4. What is ptosis?
    abnormal drooping of the lid over the pupil caused by edema or impairment of the 3rd cranial nerve
  5. What are extra ocular movements?
    Extra, abnormal eye movements noticed during the six directions of gaze testing the muscles
  6. What are the cardinal fields in the eye?
    • 1. Right and up right superior rectus and left inferior oblique
    • 2. right right lateral rectus and left medial rectus
    • 3. right and down right inferior rectus and left superior oblique
    • 4. left and up left superior rectus and right inferior oblique
    • 5. left left lateral rectus and right medial rectus
    • 6. left and down left inferior rectus and right superior oblique
  7. What is the snellen?
    Eye chart to measure visual acuity
  8. What does PERRLA stand for?
    Pupils equal, round, reactive to light and accomodation
  9. What is stribismus?
    Congenital condition in which both eyes do not focus on an object simultaneously and the eyes appear crossed. Impairment of the extraocular muschles or their nerve supply cause this
  10. What are lymph nodes?
    Collects lymph from head, ears, nose, cheeks, and lips. Can warn you of infection. Inspect areas where nodes are distributed and compare both sides, inspect for edema, erythema or red streaks, also palpate
  11. What is nasal flaring?
    Intermittent outward movement of the nostrils with each inspiratory effort, indicates an increase in the work of breathing
  12. What are muscous membranes?
    The membrane lining passages and cavities communicating with the air, consisting of a surface layer of epithelium, a basement membrane, and underlying layer of connective tissue
  13. What are sinuses?
    cavities in the skull that usually communicate with the nostrils and contains air
  14. What are the hard and soft palate?
    • Hard palate-roof of mouth, located anteriorly, dome shaped
    • Soft palate-extends posteriorly toward the pharynx, light pink and smooth
  15. What are the tonsils?
    A mass of lymphoid tissue in the muscous membrane of the pharynx and base of the tongue. The free surface of each tonsil is covered with stratified squamous epithelium that forms deep indentations or crypts, extended into the substance of the the tonsil
  16. What is the uvula?
    the free edge of the soft palate that hangs at the back of the throat above the root of the tongue, it is made of muscle, connective tissue and mucous membrane
  17. What is the buccal mucosa?
    The lining of the cheeks of the oral cavity, it is characterized by the stratified squamous non-keratinized epithelium that may become keratinized in local areas due to cheek biting, it may also contain ectopic sebaceous glands
  18. What is the tongue?
    Inspect on all sides as well as the floor of the mouth, note any deviation, remor, or limit in movement, this tests the hypoglossal nerve
  19. What is an otoscope?
    Equipment used for inspecting deeper structure of the external and middle ear
  20. What is the opthalmoscope?
    Advanced practice nurses use this to onspect the fundus, which includes the reina, choroid, optic nerve disc, macula, fovea centralis and retinal vessels
  21. What is hearing acuity?
    A hearing assessment using a tuning fork
  22. What is visual acuity?
    Visual assessment using the snellen chart. The ability to see small details, tests central vision
  23. Define photophobia?
    Intolerance to light. Painful sensitiveness to strong light. An abnormal fear of light
  24. What is nystagmus?
    An invountary, rhythmical oscillation of the eyes. Assessed by periodically stopping movement of the finger
  25. Define accommodation
    Pupils normally converge and accommodate by constricting when looking at close objects. Test:gaze at a distant object and then at a test object held close
  26. What is vertigo?
    A disordered state which is associated with various disorders of the inner ear. and in which the individual seem to whirl dizzily diordered vertiginous movement as a symptom of disease
  27. What is epistaxis?
    Bleeding from the nose
  28. What is the thyroid gland?
    A large bi-lobed endocrine gland that arises as a median ventral outgrowth of the pharynx, it lies in the anerior base of the neck or anterior ventral part of the thorax and produces hormones. Inspect the lower neck overlying the gland for obvious masses, symmetry and any subtle fullness
  29. What is cerumen?
  30. Describe the pharynx
    Part of the digestive and respiratory tracts situated between the cavity of the mouth and esophagus. It is continues above with the mouth and nasal passage, communicates through the eustachain tubes with the ears, and extends downward past the opening into the larynx to the lower border of the cricoid cartilage where it is continuous with the esophogus
  31. What is pinna?
    The largely cartilaginous projecting portion of the external ear
  32. What is the trachea?
    Tube that passes air to and from the lungs
  33. What does the integumentary system consist of?
    Skin, hair, scalp & nails
  34. What are developmental GI concerns for infants?
    small stomachs, fewer digestive enzymes, underdeveloped neuromuscular system
  35. What are developmental GI concerns for toddlers?
    acidity of gastric contents increase, stomach size increases, physiologic ability to control sphincters is present, learn control of bodily functions
  36. What are developmental GI concerns for older adults?
    decreased salivation, acid secretions, mucosal thickening, nutrient absorption, peristalsis, esophogeal emptying. Cardiovascular changes affect blood flow and absorption, less muscle tone in perineal floor and anal sphincter
  37. What are the four quadrants of the abdomen?
    Right upper, left upper, right lower, left lower
  38. What are the nine regions of the abdomen?
    Right hypochondriac, epigastric, left hypochondriac, right lateral (lumbar), umbilical, left lateral (lumbar), right iliac (inguinal), suprapubic, left iliac (inguinal)
  39. What do you look for when inspecting the rectum?
    discoloration, inflammation, hemorrhoids, lessions
  40. What do you auscultate in the abdomen?
    4 quadrants, check for bruits. Your can hear the renal artery in the RUQ, iliac artery in the RLQ, the aorta is above where the RUQ & LUQ meet, femoral artery is in the groin
  41. What do you look/listen for while percussing the abdomen?
    Resonance, tymmpany (bubble stomach), dull (organs or fluid), flatness (lower edge of liver). Check in a Z pattern and for CVA tenderness
  42. How do you palpate the abdomen?
    Very lightly, must be relaxed, check for distention
  43. What are pathological symptoms in the abdomen?
    • Hep B-infection of liver
    • Abdominal-anorexia, nausea, vomiting, enlargement of liver
    • Lactose intolerance-inability to digest milk sugar, diarrhea, flatus, abdominal pain
  44. During skin assessment what do you look for in regard to color?
    Look for pallor in face, buccal and nail beds. Cyanosis in lips nail bed and palms. Jaundice in sclera
  45. During skin assessment what do you look for in regard to moisture?
    Excessive sweating, moisture, excessive dry skin
  46. During skin assessment what do you feel for in regard to temperature?
    Palpate with dorsum of hand and document hot, warm, cold, etc
  47. During skin assessment what do you feel for in regard to texture?
    Is skin soft, smooth, even, flexible. Check palms of hands and soles of feet, they usually are thicker skinned areas
  48. During skin assessment what do you look for in regard to turgor?
    Checking for hydration and elasticity of skin. Grasp a fold of skin on back of forearm and release. Skin should snap back to normal immediately
  49. During skin assessment what do you look for as far as vascularity?
    Check circulation, variscosities, color and appearance of blood vessels
  50. Durin skin assessment what do you look for in regard to edema
    Check feet, sacral area and notice in pitting edema (accumulation of fluid under the skin) rated 1-4 depending on depth of pitting and how long it stays pitted.
  51. During skin assessment what do you look for in regard to lesions?
    Inspect for color, location, texture, size, shape, type, grouping and distribution. Measure size
  52. How do you inspect hair and scalp?
    Palpate head for any abnormalties. Inspect hair for distribution, quantity, thickness, texture, lubrication. Inspect scalp for lesions
  53. How do you inspect nails?
    • Check nail bed for color, cleanliness, length, thickness, and shape.
    • Palpate nail bed to determine firmness and cap refill, should be less than 2 seconds
  54. What is turgor?
    Elasticity of skin
  55. What is cyanosis?
    bluish skin associated with hypoxia
  56. What is pallor?
    decrease in color, reduced amount of oxyhemoglobin caused by anemia
  57. What is jaundice?
    Increased amount of bilirubin in tissues, seen in sclera of eye. Yellowing of skin caused by liver disease
  58. What is edema?
    build up of fluid in the tissues
  59. What is capillary refill?
    test for peripheral circulation, press lightly on skin to produce blanching, color should return in less than 2 seconds
  60. What is pigmentation?
    skin color, usually uniform over the body.
  61. What is hyperthermia?
    Body temperature exceeding normal. Results from external conditions creating more heat than the body can get rid of. Body not able to regulate temperature due to external conditions.
  62. What is a macule?
    flat, nonpalpable, circumscribes less than 1cm. Example is a freckle.
  63. What is a papule?
    Elevated, palpable, firm circumscribed less than 1 cm. example is a wart
  64. What is a vesicle?
    Elevated, circumscribed, superficial filled with serous fluid. Less than 1cm. Example is a blister or chicken pox
  65. What is mongolian spot?
    Bluish, black areas of pigmentation, may appear over any part of the exterior suface of the body
  66. What is a scar
    Thin to thick fibrous tissue replacing injured dermis
  67. What is a striae?
    aka stretch marks, irregular areas of skin that look like bands, stripes or lines
  68. What is an ulcer?
    Loss of epidermis and dermis. concave, varies in size, exudative, red or redish blue. Example is decubitus ulcer or statis ulcer
  69. What is a fissure?
    Linear crack or break from epidermis to dermis. Small, deep, red. Athlete's foot
  70. What is a lesion?
    Freckles or age related changes such as skin tags, thickening of skin, red papules.
  71. What is a nodule?
    Elevated, firm, circumscribed, palpable, deeper in dermis than papule, 1-2 cm. Example is erythema, lipoma
  72. What is tumor?
    Solid mass that extends deep through subcu tissue, larger than 1-2cm
  73. hat is a pustule?
    Elevated, superficial, similar to vesicle but filled with purulent fluid. Example is acne, impetigo
  74. What is a bulla?
    Vesicle greater than 1cm. Example is blister
  75. What is a wheal?
    elevated, irregularly shaped area of cutaneous edema, solid, transient, changing, variable diameter. Example is an insect bite or hives
  76. What is texture?
    Character of the skin's surface and the feel of deeper proportions are texture
  77. What is ecchymosis?
    Localized red or puple discolorations caused by extravasation of blood onto dermis and subcu tissue
  78. what is alopecia?
    Hair loss, thinning of the hair related to genetic tendencies and endocrine disorders
  79. When doing a GI assesment what do you inspect?
    mouth, abdomen, rectum
  80. When doing a GI assessment what do you auscultate?
    4 quadrants of abdomen, bowel sounds, bruits
  81. When doing a GI assessment what do you percuss for?
    Resonance, typmany, dull, flattness, z-patter
  82. When doing a GI assessment what do you palpate for?
    Very light palpation to feel for distention
  83. What is ascites?
    Accumulation of fluid in the peritoneal cavity
  84. What is feces?
    Waste products eliminated by the rectum
  85. What is peristaltic waves?
    Movement of contents through the intestines, is a normal function of the small and large intestines
  86. What are bowel sounds?
    audible passage of air and fluid that peristalsis creates
  87. What is the anus?
    Opening for elimination
  88. what is the rectum?
    stores and expels feces
  89. What is light palpatation?
    Used over abdominal quadrant. Lay palm of hand with fingers extended and palp lightly on the abdomen no deeper than 1/2 inch
  90. What are pulsations?
    Movement across the abdomen, men breath abdominally women breath costally. Dimished movement can be related to pain
  91. What is melena?
    Dark tarry stools related to GI hemmorhage
  92. What is flatus?
    Large quantities of waste and gas eliminated by the colon
  93. What is a hernia?
    protrusion of abdominal organs through the muscle wall, causes upward protrusion of the umbilicus
  94. What is the umbilicus?
    flat, concave with the color the same as that of surrounding skin
  95. What organs are in the RUQ?
    Liver, transverse colon, gallbladder, head of pancreas, hepatic flexure and duodenum, right kidney
  96. What organs are in the LUQ?
    Stomach, spleen, left lobe of liver, left kidney, and adrenal gland, body of the pancreas, splenic flexure of colon, left kidney
  97. What organs are in the RLQ?
    cecum, appendix, right ureter, right ovary and fallopian tubes, ascending colon
  98. What organs are in the LLQ?
    left ovary, fallopian tube, descending colon, sigmoid colon, left ureter
  99. What is the sequence of the GI exam?
    Inspect, auscultate, percuss, palpate
  100. What are the 4 quadrants?
    R Upper, R Lower, L Upper, L Lower
  101. What are the nine regions of the abdomen?
    • Right Hypochrondriac
    • Epigastric
    • Left Hypochrondriac
    • Right lateral (lumbar)
    • Umbilical
    • Left lateral (lumbar)
    • Right iliac (inguinal)
    • Suprapubic
    • Left iliac (inguinal)
  102. What are the normal patterns for bowel and bladder elimination?
    • Bolus travels from the mouth to the esophagus to stomach, to small intestine, then to large intestine, then anus, defecation occurs.
    • Bladder elmination occurs after 150-200 ml of urine collects in the bladder. As volume increase the bladder wall stretches sending sensory impulses to the spinal cord to void urine
  103. What are disease factors influencing urinary elimination?
    Disease conditions, socioeconomic factors, psychological factors, fluid balance, surgical procedures, medications, diagnostic examination
  104. What is micturition?
  105. What is nosocomial?
    Hospital acquired illness
  106. what is a UTI?
    Urinary tract infection, caused by bacteria getting into the urethra. Pain and burning during urination.
Card Set
Nursing 111