π- Assessment Test Flashcards
What is a sign of pallor in light skinned patients and dark skinned patients
Light skinned - extreme paleness, skin appears white loss of pink or yellow tones
Dark skinned - loss of red tones
Ashen
A blue-gray coloration of the skin also described as cyanosis
What is Ecchymosis
Bruised (blue-green-yellow) area
Petechiae
Tiny, pinpoint red or reddish-purple spots
Due to extravasation of blood into the skin
Extravasation
Leakage from vessels
Mottling
Bluish marbling splotchy
Sometimes seen in dying patients
Name a type of embolus associated with petechiae
Fat
What does trace mean in relation to pitting edema
Minimal depression with pressure
What is the acronym used to assess skin lesions
A - asymmetry B - border irregularity C - color variation D - diameter E - elevation Patterns
What is central cyanosis
Blue-gray coloration in the lips, tongue, mucous membranes and facial features
What are you looking for when inspecting the hair
Texture and distribution
Infestation or infection
What are you looking for when assessing the nails
Capillary refill
Color and texture
Shape
What is clubbing of the nails and what is it associated with
The nail plate angle is 180 degrees or more
Associated with long-term hypoxic states, such as occur with chronic lung disease
What is Hirsutism and what is a possible cause
Excess facial or trunk hair
Indicates a possible thyroid issue
What are nits
Eggs of head lice and are usually located close to the hair shaft
Which 3 cranial nerves are usually assessed together for eye movement
CN 3,4,6
What 5 things do you look for when assessing the head and face
Skin and hair Size and shape Symmetry Facial movements Scalp
When assessing the neck name 6 things to look for
Musculature Trachea Thyroid Symmetry Contour ROM - shrug CN XI
What are Striae
Silver-to-pink stretch marks in pregnant women, women who have had children and anyone who has experienced significant weight fluctuations
What are meesβ lines
Transverse white lines in the Nailbeds
Seen in clients who have experienced severe illnesses or nutritional deficiencies
What is acromegaly
A large head in an adolescent or adult
Associated with excess growth hormone
Hydrocephalus
An accumulation of excessive cerebrospinal fluid
Seen in infants and children, a head that is growing disproportionally
What are some causes of enlarged or tender nodes
Infection, malignancy and other diseases
What is enlargement with exophthalmos
Associated with a thyroid issues
Is an increase in the volume of the tissue behind the eye, the eyes will appear to bulge out of the face
Goiter
Bilateral thyroid enlargement
Name 8 things to look for when assessing the eye
External eye Sclera and conjunctiva Eye position Visual acuity Visual fields Cranial nerve function Pupils Internal structures
Ectropion
An everted eyelid
Entropian
An inverted eyelid , can lead to corneal damage
Ptosis
Dropping of the lid
What is PERRLA
Pupils, equal, round, reactive to light and accommodation
Accommodate
When pupils constrict and the eyes converge (cross) as a person attempts to focus on an object moving toward them
Mydriasis
Enlarged pupils
May be seen with glaucoma
Miosis
Constricted pupils
Anisocoria
Unequal pupils
Maybe be seen in stroke, head trauma or could be normal
Myopia
Diminished distant vision
βNear sightedβ
Presbyopia
Diminished near vision
βFar sightedβ
Strabismus
Crossed eye
Amblyopia
Lazy eye
Is a result of constant strabismus of one eye
What is 100% visual efficiency
20/20
What does the numerator of the snellen acuity chart represent
What the patient can read/see at that distance
What does the denominator of the snellen acuity chart represent
What a normal eye can read at that distance
What does it mean to say someone has 20/40 vision
Patient can read at 20ft what a normal eye can read at 40ft
What does the corneal light reflex assess
Muscle balance of the eye
Which cranial nerve does the confrontation test assess
Peripheral vision - CN IV
What is a blown pupil
One that is widened out but also not reactive to light
What is the macula
The point of central vision
The ophthalmoscope is used to view what 4 things
Red reflex (should see red dots)
Optic disk
Retinal vessels
General background
What is the proper technique for examining a patients eye with an ophthalmoscope
Examine the patients eye on the same eye you are looking through
Name 4 things you are inspecting for when assessing the ear
Alignment
Lesions and trauma
Piercings
Tympanic membrane
What could bruising behind the ear mean
Head trauma
What is the tragus
The bottom part of the ear
Otitis externa
An outer ear infection
Otitis media
A middle ear infection
What does the weber test , test for
Lateralization of bone conduction
What is considered a positive result in a weber test
If vibration is louder in one ear
What does the rinne test , test for
Test compares bone conduction and air conduction
What is cerumen
Ear wax
What is considered a positive result for a rinne test
Air conduction greater (>) bone conduction
What should a normal tympanic membrane look like
Pearly, gray, shiny and translucent B
How does the tympanic membrane appear in otitis media
Red, inflamed, drainage, bulging tympanic membrane
Cone of light disturbed