CH 2 Patient Observation- Vital Signs Flashcards
Deliberate use of senses (vision, hearing, smell, touch) to gather information about your patient
Observation
Cannot provide definitive diagnostic information; however, provides clues to underlying problems
Observation
Using a logical, consistent sequence to create a systemic approach
Observation
Pain, grimacing, difficulty breathing observed by facial expressions, use of accessory muscles for breathing, or frequent positional changes
Immediate patient distress or discomfort
Central obesity (trunk and face) and fat pads near the collarbone and back of neck
Cushing’s Syndrome
State of malnutrition or wasting associated with many chronic diseases
Cachexia
Poor hygiene (impaired self-care abilities, lack of resources, presence of wound, underlying diseases, fruity breath smell)
Disagreeable body odor
Wheezing, crackles, signs, narrowed arrows (asthma, CHF, tracheal stenosis), COPD, presence of foreign object, secretions partially blocking airway
Sound of Respiration
Profuse perspiration indicating body is working to compensate for reduced cardiac output
Diaphoresis
Abnormally increased perspiration
Hyperhidrosis
Associated with myocardial infarct, hypotension, shock, hyperthermia (faulty thermoregulation), thyroid hyperactivity, anxiety, overactive sweat glands, environmental conditions, patient participation
Diaphoresis
Cough typically resolving within 3 weeks or less (upper respiratory tract infection)
Acute cough
Cough typically lasting more than 8 weeks
Chronic/Persistent Cough
Caused by a relatively benign airway irritant (dust particles) or may indicate the presence of a disease such as asthma, bronchitis, COPD, lung cancer, pneumonia
Presence of cough
Atrophy, hypertrophy, impaired motor function, underlying disease (cerebral vascular accident), facial features during rest, movement, incoordination, or abnormal movements
Asymmetry of body parts
Largest organ of the body
Skin
Provides important preliminary data about the efficiency of the cardiovascular/pulmonary system and may be an indicator of disease, inflammation, infection
Skin Discoloration
Bluish-gray discoloration of the skin and mucous membranes
Cyanosis
Caused by hypoxia and results in color changes in central aspects of the body and mucous membranes
Central cyanosis
Caused by hypoxia with color changes in the nail beds and lips
Peripheral Cynaosis
Associated with diseases of cardiovascular and pulmonary system and CNS disorders that impair respiration
Central Cyanosis
Associated with decreased cardiac output, exposure to cold (extreme vasoconstriction), and arterial (peripheral vascular disease), or venous obstruction (deep vein thrombosis)
Peripheral Cyanosis
Caused by hypoxia from a blocked airway (asphyxiation or choking) with rapid onset of skin color changes initially in face, lips, and nail beds
Acute Cyanosis
Caused by bruising (bleeding under the skin) and may be seen anywhere on the body
Ecchymosis
New bruises appear bluish purple while older bruises appear greenish yellow; often caused by trauma (falls, sports injury, physical abuse); including patients on blood thinning agents (Coumadin) that tend to bruise easily
Ecchymosis
Reddened area of skin caused by increased blood flow (hyperemia)
Erythema
Associated with skin irritation or injury, infection and inflammation, redness over a bony prominence warns of the potential development of a decubitus ulcer
Erythema
Diffuse redness of face but may involves other body areas
Flushing
Related to emotions (embarrassment, anger), physical exertion, fever, and increased temperature of environment
Flushing
Caused by impaired liver function (hepatitis, liver cancer)
Jaundice
Skin takes on a yellow-orange hue; best observed in the sclera, mucous membranes, and palms of hands and soles of feet
Jaundice
Skin takes on a lighter tone (more white with decreased pink hue) than normal for the individual for normal “fair” skin color; for darker skin, apparent by loss of red tones
Pallor (pale)
Associated with anemia (low hemoglobin) and impaired circulation; observed in face, palms, mucous membranes, and nail beds
Pallor (pale)
Tiny red or purple hemorrhagic spots caused by capillary bleeding with subsequent leakage of blood into the skin; tends to appears in clusters and often seen on ankles and feet but can occur anywhere on the body
Petechiae
May be a sign of thrombocytopenia (low platelet count)- reducing counts impair clotting and increase risk of bleeding (can be associated with variety of medications and disorders
Petechiae
Varies with age and poor nutritional status
Skin texture
May be indicative of pathological changes or trauma
Skin lesions
Typically lack hair growth on the legs and display thickening of nails of the fingers and toes
Diabetes mellitus or Atherosclerosis
Nails should be pink (light brown in dark skinned individuals) and free of irregularities
Normal circulation and oxygen supply of nails
Deep grooved (indented) transverse lines across the nail resulting from disruption of nail growth caused by trauma or disorders such as Raynaud’s disease (decreased blood flow to fingers), psoriasis, or infection around nail plate
Beau’s Lines
Caused by blood under the nail and results from trauma
Black Nails
Bulbous swelling of fingertips secondary to proliferation of connective tissue between the nail matrix and distal phalanx accompanied by the nail bed and skin
Clubbing
Nails appear bluish gray (cyanotic) and become soft and boggy (spongy)
Clubbing
Develops gradually over time and is associated with diagnoses that involve long-standing hypoxia such as congenital heart defects and cardiopulmonary diseases
Clubbing
Seen with renal failure
Half-and-half nails (Lindsay’s nails)
The distal portion of the nail turns red, pink, or brown; there is a distinct line of demarcation between the two halves
Half-and-half nails (Lindsay’s nails)
Detachment of the nail from the nail bed
Onycholysis
Associated with trauma, fungal infections, psoriasis, and overactive thyroid gland
Onycholysis
Transverse white lines across the breadth of the nail
Mee’s Lines
Associated with systemic diseases such as renal failure, Hodgkin’s disease, malaria, and sickle cell anemia
Mee’s Lines
Classically associated with arsenic poisoning
Mee’s Lines
Characterized by tiny punctate depressions in the nail
Pitting
Caused by systemic diseases such as Reiter’s syndrome, psoriasis, and eczema
Pitting
Tiny hemorrhages creating reddish lines of blood under nail
Splinter Hemorrhages
Associated with bacterial endocarditis and trauma
Splinter Hemorrhages
Suggestive of pain or structural abnormalities of pelvis, pectoral, or vertebral regions that may interfere with respiratory patterns
Abnormal posture
May be associated with CHF, liver failure, lymphedema, or venous insufficiency
Edema
May result from varicose veins, thrombophlebitis, or trauma
Localized edema
