2410wk1&2 (exam 1) Flashcards
what are approaches to assessment
- cephalocaudal
- least to most invasive
- validate subjective data (episodic, complaint, injury or discomfort
- screening
- comparison
planes of the body
coronal (anterior posterior
transverse (proximal distal)
sagittal (medial or lateral)
patient positions
standing sitting high fowler semi fowler recumbant/supine sims lithotomy knee chest
what can fruity/ metallic/offensive breath be indicative of
fruity: metabolic disorder accomopanied by acidosis or pseudomonas
metallic: Gi bleed
offensive: poor oral hygiene dental caries bronchitis
describe light palpation and use
pressing 1/2 to 3/4 inch check surface characteristics lesions superficial masses muscle tone, tenderness
describe palpation and use
press 2in’ identify organs identifies abnormal organs or masses
what info is gathered from percussingq
size location
density structure
detects masses elicits pain
deep tendon reflexes
with indirect percussing idenifty hands
stationery hand: pleximeter
striking hand: plexor
describe 6 percussion notes
- softer note: denser structure
- resonant: heard over lungs
- hyperresonant : heard over child’s lung
- tympany: stomach and intestines
- dull: heard over spleen
- flat: heard over muscle.
define auscultation
listening to sounds through use of stethoscope
what is bruits
turbulence
what are adventitious sounds and give an example
abnormal sounds : such as wheezing
what sounds would you use the diaphragm or belll for when ascultating
bell: low pitches
diaphragm: high pitches
what range is norm for temp
96.9-99.4
what are age related variables in temp
elderly: less likely to develop fever
children: reduced capacity to regulate temp
what is the temp measurement conversion
faren: (C x 9/5) +32
Cels: (F-32) x 5/9
when to report temp
- changed from baseline
2. spikes greater than 101 F
what info does pulse give (4)
- strength of heart’s contraction
- rhythm
- volume of blood
- patency
give range and cause for bradycardia and tachycardia
brady: less than 60 (athletes cardiac meds)
tachy: more than 90-100 (loss of blood decreased O2)
what is sinus arrthmia
HR increase and decrease with breathing
variations in infant HR
brady: less than 80
tachy: more than 190
kids less than 3 take hr apically
causes of tachy HR
emotions & stress exercise fever anemia disease (shock hemorrhage hypoxia
causes of brady HR
vagal/valsalva response (vomitting or pooping)
medications
hypothermia
what is PMI and where is it found
Point of maximum intensity Apical Pulse 5th ICS MCL
what are the five pulse types
- norm
- weak
- increased: bounding
- pulsus alternans: strong pulse followed by weak pulse
- pulsus paradoxus: a regular rhythm of increassed then decreased pulse associated with resp
respirations rates in infants children and adults and ratio
infants: 30-40
children: 20-30
adults 10-20
ratio–> 4:1
define eupnea, bradypnea, tachypnea, hypoventil, hyperventil
eupnea: normal 12-20
bradypnea: less than 12
tachypnea : more than 20
apnea: absence
hypoventilation: rate and depth decreased
hyperventilation: rate and depth increased
define dyspnea, orthopnea, cheynes stokes, kussmaul
dyspnea: SOB
othopnea: difficulty breathing while laying supine
cheynes stokes: alternating apnea hypovent and hypervent
kussmaul: rate and depth increased (seen with dsieases)
3 statement about BP
1 gives info on PT cardiovascular & circulatory sys
2 BP stated in term of mmHg
3 measures pressure of blood against arterial wall
define systole and diastole & pulse pressure
sys: contrax at its height (max pressure ventricular contrax)
diastole: ventricular relaxn, resting pressure btw contraxn
pp: reflects stroke volume difference between sys and dias (norm 30-50)
4 factors that influence bp
- blood volume: decrease BV decrease BP
2 axn of <3: increase pump axn increase BP - resistance of vessels: decrease elastic/increase blood viscosity = increase BP
- cultural diff: HTN in black ppl
NIH BP ranges
optimal: less than 120/80
norm: less than 130/85
pre-HTN: 130-139/85-89
stg 1: 140-159/90-99
stg 2: 160-179/100-109
stg 3: greater than 180/110
bp cuff dimensions
width = 40%
length= 80%
cover 2/3
bp sites
bicep: brachial
forearm: radial
thigh: popliteal
define auscultory gap
no sound btw phase 1 & 2, common in HTN, results in false low BP reading
where to apply pulsox
finger toe earlobe bridge of nose
infants/children: palms soles
factors that affect pulsox reading
increase 1 dark skin 2 moisture 3 finger nail polish 4 acrylic nails 5 jaundice 6 low hemoglobin decrease poor capillary refill/perfusion
3 p’s of diabetes
polyuria
polyphagia
polydipsia
glucose level ranges norm acute panic medical fasting random norm
norm:70-106
acute: below 55 or above 400
panic: below 40 above 700
medical fasting: normal should be below 120
random blood glucose: below 200
s/s hyperglycemia
warm dry skin dry mucousal membrane tachy<3 weak thready pulse hypotension 3 Ps
s/s hypoglycemia
cool and clammy headache impaired motor funx anxiety hypotension tachy<3
describe structure of skin
epidermis: outer layer melanocytes
dermis: supportive layer of connective tissue or collagen, skin appendages
subq tissue: adipose tissue
skin developmental factors for infants and children
- more permeable to h2o
- sebacious glands
- temp regulation is immature (b/c of less eccrine glands & subq tissue, cannot shiver)
- pigment system not well developed
define:
xerosis
seborrhea
diaphoresis
xerosis: excessive dryness of skin
seborrhea: oiliness
diaphoresis: excessive moisture
define:
pruritis
alopecia
hirsutism
pruritis: itchiness
alopecia: hair loss
hirsutism: excessive hair
causes of: pallor erythema cyanosis jaundice
- pallor: fear peripheral vasoconstrict. smoking shock anemia
- erythema: fever, inflamm, polycythemia
- cyanosis: hypoxia, shock, <3 failure
jaundice: liver problem (cirrhosis, hep ABC, sickle cell
annular lesion
confluent
discrete
Annular: circular (ringworm)
confluent: run together (hives)
discrete: distinct, remains separate (pimple)
grouped
gyrate
target
- clusters (contact dermatitis)
- twisted (poison ivy)
- lesion with in lesion (like bulls eye seen in lyme disease or erythema multiforme)
linear
zosteriform
- scratch of streak
- linear along a nerve route (shingles)
macule
patch
papule
- flat circumscribed 1cm (cafeaulait spot, vitiligo)
- solid, elevated circumscribe, <1cm (wart)
plaque
nodule
tumor
- coalesced papules that form an elevation >1cm (psoriasis)
- solid, elevated, hard/soft >1cm deeper in dermis (fibroma)
- > 2cm firm/soft (lipoma)
wheal
uriticaria
vesicles
- superficial, raised, transient, erthematous,2ndary to edema (hive)
- hives, coalesced wheals, intensely pruritic
- elevated lesion containing fluid < 1cm (herpes)
bulla
cyst
pustule:
- > 1cm elevated fluid filled cavity(burn blister)
- encapsulated fluid filled cavity in dermis or subq layer (sebacious cyst, ganglion)
- <1cm turbid fluid (pus) filled cavity (acne)
crust
scale
fissure
erosion
- thickened dried exudate when vessicle/pustule burst
- flakes of skin, excess keratin (psoriasis, eczema)
- linear crack, extending to dermis (athlete’s foot)
- shallow scooped out depression, superficial dermis loss (Stg II DPU)
ulcer
excoriation:
lichenification
- deeper depression, extending to dermis (stg III DPU)
- superficial self inflicted scratch
- thickening of skin, happens with prolonged scratching or rubbing
difference b/w primary vs secondary lesion
primary lesion: is the first appearance
secondary : altered state of primary lesion
(Vascularity and Bruising)
angioma
telangiectasis
echymosis:
- 1-5mm smooth, slightly raised bright red, blanchable (develop on trunk common with aging)
- [ Tell Angie Hector’s Sis] blanchable fiery red star shaped lesion on face neck chest, seen with liver disease pregnancy estrogen therapy
- bruising
(Hemangiomas)
portwine stain
strawberry mark
- benign proliferation of blood vessels, flat macular patch covering scalp or face along CN V, at birth, color deepens with exertion, stress
- macular plaque covering scalp or face, raised red, immature capillaries, at birth but resolves by 5-7 y.o.
ABCDE danger signs of lesions
Asymmetry Border irregularity Color variation Diameter >6mm pencil eraser Elevation/enlargement
malignant melanoma
cause, at risk, ratio of occurence
UV exposure, blued-eyed blondes or gingers
basal cell carcinoma 5 characteristics
- most common
- least malignant
- 2ndary to UV exposure
- non healing sores
- nodular, on head hands and back
Describe 2 skin lesions seen in aging population
- seborrheic keratosis-crusty raised thickened areas of pigmentation on trunk, face, and hands
- acrochordons- skin tags
petechiae
purpura
- nonblancable tiny red, purple, brown macules caused by bleeding from superficial capillaries, this is associated with low platelets
- extravasation or bleeding into tissues
mobility/turgor test site
cause of decreased turgor
define tenting
- anterior chest under clavicle (children abdom.)
- edema or dehydration
- poor turgor, tissue will stand by itself (indicative of dehydration)
tinea capitis alopecia areata trichotillomania pediculosis capitis furuncle
- ringworm on scalp
- round patch of hair loss
- self inflicted hair loss
- lice
- infected hair follicle
what is the schamroth technique, what does abnorm finding indicate
examining nailbase 160 degrees or less, increased angle seen in chronic hypoxia (clubbing) or cardiac or resp. dz
what does sluggish return indicate when pressing nailbed, time of norm return
problems with periph. circulation, 3 sec. norm
koilonychia beau's lines paronychia onycholysis onychodystrophy
- spoon nail
- transverse (horizontal) groove
- inflamm of nail folds
- loosening of nail bed
- thickening of toe nail
what causes DPU
Decubitus Pressure Ulcer- localized ischemia (decreased blood supply) subsequent tissue necrosis
etiology of DPU (6 statements)
- pressure to tissue b/w bed and bony prominence
- ischemia
- after pressure –> area of pale skin
- removal of pressure –> skin bright red (reactive hyperemia)
- disappearance of redness –>no perm. damage
- persistent redness –> damage to tissue
when does shearing happen commonly
what is maceration
- fowler’s position, body sliding with pressure of PT’s body weight
- softening of tissue (incontinence)
DPU risk factor associated with body temp
excessive body heat causes increased BMR, cells have increase need for o2
describe 4 stages of DPU
I. non blanchable erythema
II. partial thickness skin loss: abrassion blister shallow crater involves epidermis & possibly dermis
III. full thickness skin loss, necrosis to subq tissue may extend to fascia bu not through it
IV. full thickness skin loss, necrosis damage to muscle, bone or supporting structure
6 subscales from braden scale assessment
possible points
score that indicates at risk for DPU
how often charted
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction/shear
-23
<18
Q 48hrs.
