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Fundamentals of Nursing, 9th Ed., Potter, Perry, Stockert & Hall, 2017 | Registered Nurse (RN) School Study Aid

31 - Health Assessment and Physical Examination
52 Picmonics to Learn | 1 hr 15 mins
Patient Position Overview
Position Techniques
Trochanter Roll
Trapeze Bar
Ankle-Foot Orthotic (AFO) Devices
Positions
Fowlers Position
Supine Position
Trendelenburg
Side-Lying Position
Prone Position
Sims' Position
Nursing Considerations
Reposition q2 Hours/Prevent Skin Breakdown
Confirm Body Alignment
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2 mins
Testicular Carcinoma Assessment
Cause/Mechanism
Seminoma Germ Cells
Non-Seminoma Germ Cells
Assessment
Painless Scrotal Mass
Testicular Swelling
Acute Pain Rare
Elevated Serum Tumor Markers
Considerations
Males Between 15-35 Years Old
Cryptorchidism
Testicular Self Exam
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2 mins
Breast Cancer Diagnosis
Mammography
Ultrasound
MRI for High Risk Patients
Confirmed with Biopsy
Considerations
Lymph Node Involvement
Receptor Positivity
Estrogen and Progesterone Receptors
HER-2
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2 mins
Cervical Cancer Assessment
Cause/Mechanism
Human Papillomavirus (HPV)
Assessment
Metrorrhagia
Leukorrhea
Pain
Abnormal Pap Test
May Be Asymptomatic
Considerations
HPV Vaccine
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2 mins
Colorectal Cancer Assessment
3rd Most Common Cancer
Assessment
Change in Bowel Habits
Bowel Obstruction
Rectal Bleeding
Anemia
Weight Loss
Ascites
Considerations
Colonoscopy
FOBT and FIT
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2 mins
Prostate Cancer Assessment
Most Common Cancer in Men
Assessment
Mimics BPH
Metastasis to Back
Low Back Pain
Fatigue
Considerations
Prostate Specific Antigen (PSA)
Digital Rectal Examination (DRE)
Transrectal Ultrasound (TRUS)
Biopsy
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2 mins
Skin Anatomy
Characteristics
Epidermis
Keratinocytes
Melanocytes
Dendritic Cells
Merkel Cells
Dermis
Sweat Glands
Hair Follicles
Sebaceous Glands
Hypodermis
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3 mins
Skin Functions
Characteristics
Thermoregulation
Protection
Innate Immune Protection
Synthesize Vitamin D
Water and Salt Excretion
Dilated Capillaries are a Blood Reservoir
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2 mins
Types of Burns
Superficial Thickness
Sunburn
Superficial Partial Thickness
Blisters
Blanching
Deep Partial Thickness
Little or Non-blanching
Full Thickness
Waxy White, Yellow or Black
Decreased Pain
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2 mins
Interventions for Impaired Skin Integrity
Assessment
Signs of Skin Breakdown
Pain
Redness
Decreased Skin Turgor
Bleeding
Bony Prominences
Intervention
Reposition Q2H
Pressure Relief
Maintain Clean and Dry Skin
Adequate Nutrition and Hydration
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2 mins
Pressure Ulcers
Types
Stage 1 - Non-Blanchable Redness
Stage 2 - Partial Thickness
Stage 3 - Full Thickness Skin Loss
Stage 4 - Full Thickness Tissue Loss
Unstageable
Possible Deep Tissue Injury
Considerations
Skin Color Alterations
Remove Necrotic Tissue Before Staging
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2 mins
ABCDEs of Melanoma
Asymmetry
Border
Color
Diameter
Evolving
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1 min
Eye
Characteristics
Sclera
Cornea
Iris
Lens
Ciliary Muscles
Optic Nerve
Rods
Cones
Retina
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1 min
Age-Related Macular Degeneration (AMD)
Mechanism
Dry (nonexudative)
Wet (exudative)
Signs and Symptoms
Scotomas
Blurred, darkened vision
Loss of central vision
Distortion of vision
Considerations
Drug Therapy
Surgery
Low-vision assistive devices
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2 mins
Primary Open-Angle Glaucoma (POAG - Chronic)
Mechanism
Flow of Aqueous Humor Slowed
Signs and Symptoms
Slow Onset
No Pain
Tunnel Vision
IOP 22-32mm Hg
Considerations
Drug Therapy
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1 min
Primary Angle-Closure Glaucoma (PACG - Acute)
Mechanism
Rapid Increase in IOP
Signs and Symptoms
Rapid Onset
Pain
Blurred Vision
Halos Around Lights
Nausea and Vomiting
IOP over 30 mm Hg
Considerations
Drug Therapy
Surgery
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1 min
Cataract
Mechanism
Age-related
Assessment
No Pain
Cloudy Opaque Lens
Decreased Visual Acuity
Occurs Gradually
Treatment
Surgery
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1 min
Aminoglycoside Side Effects
Side Effects
Ototoxicity
Nephrotoxicity
Respiratory Paralysis
Contraindications
Pregnancy
Considerations
Peak and Trough
Never Mix with Penicillin in Same IV
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2 mins
Oral Cavity
Characteristics
Mouth
Mechanical Digestion
Salivary Amylase Begins Carbohydrate Breakdown
Lingual Lipase Begins Lipid Breakdown
Esophagus
Bolus
Peristalsis
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1 min
Muscles of Mastication
Temporalis
Masseter
Medial Pterygoid
Lateral Pterygoid
Innervation
Mandibular Branch (V3) of Trigeminal Nerve
Embryology
1st Branchial Arch
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1 min
Neck and Shoulder Muscles
Superficial
Splenius Capitis
Trapezius
Rhomboid Minor
Rhomboid Major
Deltoid
Latissimus Dorsi
Deep
Levator Scapulae
Supraspinatus
Infraspinatus
Teres Minor
Teres Major
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2 mins
Lymphatics
Characteristics
Recycles 10% of Interstitial Fluid
Transport Large Lipids from Lacteals
Unidirectional Valves
Lymph Nodes Filter Lymph
WBCs Monitor Lymph for Pathogens
Merge with Veins
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2 mins
Respiratory Anatomy
Characteristics
Nasal Cavity
Hair Filters
Mucus Filters and Moistens
Capillaries Warm
Pharynx (Throat)
Larynx (Voice Box)
Cilia Expel Mucus and Dust
Trachea
Bronchi
Alveoli
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2 mins
Thyroid Gland
Characteristics
TSH Stimulates T3 and T4 Release
Metabolism Regulation
Blood Calcium Sensor
Calcitonin Release
Blood Calcium Decreases
Bone Building
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2 mins
Lung Sounds - Wheezes
Location
Throughout Lung
Description
High Pitched
Sounds Like
Musical
Cause
Air Moving through Narrowed Airways
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38 secs
Lung Sounds - Pleural Friction Rub
Location
Anterior Lateral Lung
Description
Dry, Rubbing, or Squeaking
Sounds Like
Rubbing a Balloon with Finger
Cause
Inflamed Pleura
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50 secs
Lung Sounds - Crackles
Location
Lower Lobes
Description
Fine/Coarse
Sounds Like
Fine: Twisting Hair through Fingers
Coarse: Velcro
Cause
Collapsed Small Airways and Alveoli "Popping Open"
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1 min
Lung Sounds - Rhonchi
Location
Trachea and Bronchi
Description
Low Pitched Rumbling
Sounds Like
Gurgling
Cause
Narrowed Airway
Secretions or Bronchospasm
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49 secs
Bile Acid Resins
Indications
Hyperlipidemia
Mechanism of Action
Bile Acid Reabsorption Prevented
Decrease LDL
Drugs
Colestipol (Colestid)
Cholestyramine (Questran)
Colesevelam (Welchol)
Side Effects
GI Distress
Cholesterol Gallstones
Decreased Absorption of Fat-soluble Vitamins
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2 mins
Leg Arteries
Descending Aorta
Iliac (Ilium)
Common Femoral
Deep Femoral
Superficial Femoral
Popliteal
Anterior Tibial
Posterior Tibial
Peroneal
Dorsalis Pedis
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2 mins
Leg Veins
Inferior Vena Cava
Common Iliac (Ilium)
External Iliac (Ilium)
Great Saphenous
Femoral
Popliteal
Small Saphenous
Anterior Tibial
Posterior Tibial
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1 min
Benign Prostatic Hyperplasia (BPH) Assessment
Assessment
Men Over 50
Enlarged Prostate Gland
Urinary Retention
Weak Urine Stream
Frequency
Urgency
Nocturia
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1 min
Osteoporosis Assessment
Highest Risk
Postmenopausal Women
Long Term Corticosteroids
Assessment
Kyphosis
Dowager's Hump
Loss of Height
Back Pain
Pathologic Fractures
Spinal Compression Fracture
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1 min
Osteoporosis Interventions
Increased Calcium Intake
Vitamin D Supplements
Bisphosphonates
Raloxifene
Denosumab
Calcitonin
Teriparatide
Bone Densitometry (DEXA) Scan
Weight Bearing Exercises
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2 mins
Neurovascular Assessment 6 P's
Pain
Paresthesia
Pulse
Pallor
Pressure
Paralysis
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1 min
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
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3 mins
Cranial Nerve Function
Sensory
CN I
CN II
CN VIII
Motor
CN III
CN IV
CN VI
CN XI
CN XII
Both
CN V
CN VII
CN IX
CN X
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1 min
CN I
Olfactory Nerve
Sensory
Smell
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36 secs
CN II
Optic Nerve
Sensory
Vision
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35 secs
CN III
Oculomotor Nerve
Motor
Eye Movement
Accommodation
Eyelid Opening
Pupillary Constriction
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1 min
CN IV
Trochlear Nerve
Motor
Abducts, Depresses, Internally Rotates
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48 secs
CN V
Trigeminal Nerve
Sensory
Facial Sensation
Motor
Mastication Muscles
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1 min
CN VI
Abducens Nerve
Motor
Abducts Eye
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48 secs
CN VII
Facial Nerve
Lacrimation
Salivation
Sensory
Taste from Anterior 2/3 of Tongue
Motor
Facial Movement
Stapedius Muscle
Eyelid Closing
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1 min
CN VIII
Vestibulocochlear Nerve
Sensory
Hearing
Balance
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55 secs
CN IX
Glossopharyngeal Nerve
Sensory
Taste from Posterior 1/3 of Tongue
Monitoring Carotid Body and Sinus
Motor
Stylopharyngeus
Swallowing
Salivation
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1 min
CN X
Vagus Nerve
Sensory
Aortic Arch Chemoreceptors and Baroreceptors
Taste from Epiglottic Region
Motor
Swallowing
Palate Elevation
Talking
Coughing
Midline Uvula
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1 min
CN XI
Accessory Nerve
Motor
Head Turning
Shoulder Shrugging
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36 secs
CN XII
Hypoglossal Nerve
Motor
Tongue Movement
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34 secs
Dermatomes - Cervical
C2 - Posterior Cap Distribution
C3 - High Turtleneck
C4 - Low Collar Shirt
C5 - Anterolateral Shoulder
C6 - Thumb
C7 - Middle Finger
C8 - Pinky Finger
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1 min
Dermatomes - Thoracic
Characteristics
T1 - Medial Arm
T4 - Nipple
T7 - Xiphoid
T10 - Belly Button
T12 - Pubis
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58 secs
Dermatomes - Lumbosacral
L2 - Medial Thigh
L3 - Medial Knee
L4 - Kneecap, Medial Ankle and Big Toe
L5 - Dorsum of Foot
S1 - Lateral Foot, Posteriolateral Thigh
S 2, 3, 4, 5 - Perianal and Genitals
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2 mins

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