deck_1093758 Flashcards
Elasticity of skin
Skin turgor
Swelling
Edema
Feel or sound of cracking rattling or rough surfaces rubbing together
Crepitation
Extreme sweating
Diaphoresis
Skin redness
Erythema
Itching
Pruritis
Hives, intense itching
Urticaria
Excessive hair
Hirsutism
Loss of hair
Alopecia
Yellowing of skin or eyes
Jaundice
Blue skin, nails or lips
Cyanosis
Pale, grey tone to skin
Pallor
Annular, confluent, generalized
Lesion shapes
Ring shaped, central clearing (bullseye)
Annular
Flowing, blending areas
Confluent
Scattered all over body
Generalized
Macule, papule, patch, plaque, wheal, nodule, tumor, vesicle, bulla, pustule, cyst
Primary lesions
Flat, circumscribed ;less than 1cm in diameter
Macule
Elevated and firm; Less than 1 cm in diameter; Example would be a wart
Papule
Flat non palpable and irregular shape and less than 1 cm in diameter
Patch
Elevated firm rough lesion greater than 1 cm in diameter
Plaque
Elevated solid irregular shaped area of cutaneous edema
Wheal
Elevated firm circumscribed lesions; Deeper in dermis then and papule; 1 to 2 cm in diameter
Nodule
Elevated and solid lesion; May or may not be clearly demarcated; Deeper in dermis and greater than 2 cm in diameter
Tumor
Elevated circumscribed and superficial; Not into dermis; Filled with serous fluid and less than 1 cm in diameter
Vesicle
Vesicle greater than 1 cm in diameter
Bulla
Elevated superficial lesion; Similar to a vesicle but filled with purulent fluid
Pustule
Elevated circumscribed encapsulated lesion; in dermis or subcutaneous layer usually filled with fluid or semisolid material
Cyst
Callus, corn ,excoriation ,ulcer
Secondary skin lesions
Loss of epidermis ;linear hollowed out crusted area
Excoriation
Loss of epidermis and dermis usually concave and varies in size
Ulcer
A horny mass of condensed epithelial cells overlying a bony prominence
Corn
A common usually painless thickening of the stratum corneum at locations of external pressure or friction
Callus
Petechiae, ecchymosis
Vascular skin lesions
Tiny flat reddish purple non-blanchable spots in the skin less than 0.5 cm in diameter; Appear as tiny Red spots pinpoint to pinhead in size
Petechiae
Reddish purple non blanchable spots of variable sizes
Ecchymosis (bruise)
Opacity of the crystalline lens of the eyes
Cataracts
Great ring composed of lipids deposited in the Peripheral cornea; commonly seen in older adults
Arcus senilis
Double vision
Diplopia
disease characterized by abnormally increased intraocular pressure caused by obstruction of the outflow of aqueous humor
Glaucoma
Abnormal Forward placement of the eyeball
Exophthalmos
Condition in which the pupil is constricted ;usually drug-induced
Miosis
Dilation of the pupil; usually drug-induced
Mydriasis
Involuntary rhythmical movement of the eyes oscillations maybe horizontal vertical rotary or mixed
Nystagmus
Condition in which the eyes are not directed at the same object or point ; cross eyed
Strabismus
Drooping of the upper eyelid ;can be unilateral or bilateral
Ptosis
The outer structure of that ear consisting of the auricle and external acoustic meatus .sound waves are funneled through the external ear to the middle ear
External ear
The tympanic cavity with the auditory ossicles contained in an irregular space in the temporal bone.it is separated from the external ear by the tympanic membrane from the inner ear by the oval window the auditory station to hear from the posterior nasopharynx into the middle ear also called tympanic cavity
Middle ear
Complex inner structure of the ear containing receptors for carrying and balance
Inner ear
Tube lined with mucous membrane that joins the nasopharynx and the tympanic cavity
Eustachian tube
Thin semi transparent membrane in the middle ear that transmit sound vibrations to the internal ear By means of the auditory ossicles ; pearly color
Tympanic membrane
Waxy secretion of the glands of the external acoustic meatus also known as earwax
Cerumen
Tinkling or ringing sound heard in one or both ears
Tinnitus
Pertaining to the inside of The cheek the surface of the tooth for the gum beside the cheek
Buccal
A small cone shaped tissue suspended midline from the soft palate
Uvula
Pertaining to the gum
Gingiva
Difficulty speaking
Dysphasia
Bleeding from the nose
Epistaxis
Appraisal of an individual’s perception of his or her intellectual awareness potential for growth and recognition by others for his or her mental skills and contributions
Cognitive function
Perpetual distortion of an external stimulus; inaccurate perception
Illusion
Sensory perception that does not arise from an external stimulus can be auditory visual tactile gustatory or olfactory; experience stimuli that do not exist
Hallucination
Referring to the bottom surface of the foot
Plantar
A neurologic condition in which language function is absent or severely impaired
Aphasia
Inability to coordinate muscular movement; referring to gait
Ataxia
Ability to recognize objects by the sense of touch
Stereognosis
Awareness of body posture movement and changes in equilibrium originating from sensory nerve endings within Muscles and tendons
Proprioception
Abnormal sensation Such as numbness or tingling
Peristhesia
Increased tone or Contractions of muscles causing stiff and awkward movements seen with upper motor neuron lesions
Spasticity
Continuous and voluntary trembling movement of a part or parts of the body
Tremor
Sensation of moving around and of objects moving about themselves resulting in disturbance of individuals equilibrium ; sense that you are spinning
Vertigo
Test of cerebral or function that evaluates an individuals ability to maintain a given position when standing erect With feet together and eyes closed
Romberg exam
Six sets of muscles that control movement of the eyeballs
Extra-ocular movements
A measure of the resolving power of the eye particularly with its ability to distinguish letters and numbers at a given distance ;measures optic nerve
Visual acuity
A mental state characterized by disorientation regarding time place person or situation it causes the wilderness perplexity black orderly thought and inability to choose or act decisively and perform ADLs
Confusion
The conscious recognition and interpretation of sensory stimuli that serve as a basis for understanding learning and knowing or promoting a particular action or reaction
Perception
Unstable characterized by Tendency to change or be altered or modified
Labile (lability)
Hole that leads to tear duct
Puncta
Inflammation of the gingiva with symptoms that Include redness swelling and bleeding
Gingivitis
Offensive breath resulting from poor oral hygiene
Halitosis
Abnormal contact between the teeth of the other Jaw and those of the lower jaw
Malocclusion
The free discharge of the thin watery nasal fluid
Rhinorrhea
A clear state of awareness of the self and the environment in which attention is focused on media matters as distinguished from mental activity of an unconscious or subconscious make
Consciousness
The awareness of one’s physical environment with regard to time place in the identity of other people
Orientation
State or quality of dullness prolonged sleepiness sluggishness or serious drowsiness
Lethargic
Anterior to the auricle of the ear
Preauricular
Posterior to the auricle of the ear
Postauricular
Highly vascular organ at the front of the neck usually weighing about 30 g consisting of bilateral lobes connected in the middle by a narrow isthmus
Thyroid gland
Any discharge from the external ear
Otorrhea
The mucous membranes lining the inside of the mouth
Buccal mucosa
A tooth disease caused by the complex interaction of food especially starches and sugars with saliva in the bacteria that form dental plaque
Caries
Paralysis of the lower portion of the body and of both legs
Paraplegia
Ability to recognize outlines numbers words or symbols traced or written on the skin
Graphesthesia
Correspondence in shape size and related position at parts on opposite sides of the body
Symmetry
The back or posterior surface of a part
Dorsum
Relaxed flabby having defective or absent muscular tone
Flaccidity
Paralysis of one side of the body
Hemiplegia
Dysphasia
Difficulty speaking
Thinking outside of the box ; critical thinking
Abstract reasoning
Retrieval of events from the past
Recall memory
Ability to recall events from immediate past
Recent memory
Ability to recall events from long ago
Remote memory
What the thought is about
Thought content
What to do with that thought
Thought process
Along in a straight line ; head above chest etc
Alignment
Dorsal flexing of foot ; normal adult curls toes ; abnormal big toe curls and others fan
Babinski test
Improved sanitation in battle fields ; developed 1st program for training nurses; disease prevention/ nursing research
Florence Nightingale
feminist ; womens rights ; responisble for push for nursing control
Lavina Dock
advocate for public health ; planned parent hood
Margaret Sanger
developed first school for midwifery
Mary Breckenridge
founder of community health
Lillian Wald
founder of the Red Cross
Clara Barton
method of what we do as a way of life ; responsibility /commitment
Professionalism
Implementing nursing interventions without an order from a physician ; responsibility
Autonomy
organization that works to improve standards of health and availability of care ; create high standards for nursing and promote development and welfare for nurses 1896
ANA american nurses association
advances nursing education to prepare nurses for ever changing needs ; accredit our nursing program
NLN nation league of nursing
main focus is greater career development and preparation for liscensure
national student nurses association
what defines a profession?
requires a basic liberal foundation and extended education of its members ; body of knowledge leading to skills; specific service ; member have autonomy ; code of ethics
Clue the patient in ; get help ; check your footing; move close ; lift ; smooth and synchronized ; turn, don’t twist ; don’t lift when you can push or pull ; teach and preach
ten commandments of body mechanics
helps with upper body strength ; give them something to do in their care
trapeze bar
give support; guides pts ; pt safety
gait belts
lateral movers
slide boards
reserved for total care pts
mechanical lifts
increased muscle mass due to exercising or training
hypertrophy
increased muscle tone that interferes with movement
spasticity
impaired muscle strength , weakness, or paralysis
paresis
decreased muscle mass die to disuse or neurologic impairment
atrophy
a slight residual tension in a resting normal muscle
muscle tone
paralysis of the arms and legs due to trauma or disease
quadriplegia
decreased muscle tone due to disuse or neurologic impairment
flaccidity
weakness or paralysis on one half of the body
hemiparesis
primary data resources
pt
secondary data resources
family ; records; physician
obtaining data so a plan that promotes health, prevents diseases, resolves acute health problems and minimizes limitations related to chronic health problems
health interview/health history
Introduction ; describe process of interview ; describe purpose of interview
orientation phase
use various communication techniques to collect data
working phase
summarize data with pt ; allow pt to clarify ; validate that pt understands the problems
termination phase
patient experiences these
subjective data
something you see
objective data
non therapeutic communication techniques that cause obstacles when collecting a history
probing ; not listening ; being too personal; changing the subject; jargon ; patronizing
therapeutic communication techniques that will enhance data collection
silence ; general leads; be specific ; ask open ended questions
longer times for processing ; visual impairments; more history
special considerations used when interviewing an older adult
allow time for play ; include the child
special considerations when interviewing a child
treat them like an adult ; right to privacy ; need reassurance of what is normal
special considerations when interviewing an adolescent
male female interactions; eye contact ; distances ; modesty
cultural considerations when doing a health interview
visual, palpate, percuss , listen
physical assessment techniques
used to auscultate low pitched sounds such as extra heart sounds
bell
used to auscultate high pitched sounds such as breath and bowel sounds
diaphragm
symptoms include tachycardia , confusion, flush , hot and dry to touch , high temp present
heat stroke
profuse diaphoresis with excess water and electrolyte loss ; weakness, normal temp, nausea
heat exhaustion
factors that affect accuracy of pulse ox readings
polish, cold, circulation /PVD, edema, hypothermia, hypo-tension, dark skin, jaudice
diastolic at rest above 90 mmhg ; systolic pumping above 140mmhg
hypertension
systolic falls below 80mmhg
hypotension
even inhalation and exhalation
normal respiratory pattern
rapid reparations
tachypnea
abnormal breathing pattern characterized by progressively deeper and faster breathing followed by a gradual decease followed by apnea
cheyne stokes
rapid and deep breathing
kussmauls
using a stethoscope with too long of tubing; using a cuff that is too wide for clients arm; positioning the arm above the heart; not pumping the cuff up high enough ; deflating the cuff too quickly
false low bp reading
not centering the cuff over the artery; putting the cuff on too lose; using a cuff that is too narrow for the clients arm; over inflating the cuff
false high bp
