Exam 1 Flashcards
Nursing diagnosis is concerned with?
Impact of of health on the individual and caring
SOAP
Subjective, objective, assessment, plan
Subjective?
Symptoms as reported by patient
Objective?
Observed signs
Comprehensive database
Traditional H&P
Episodic databse
Problem centered
Follow Up Database
Problem centered, f/u on stable patient
Emergency Database
ABCs
Components of classic H&P
Chief complaint, history of present illness, past medical history, current health history, social/occupational/family history, functional assessment, review of systems, physical exam
Analyze symptom using…
PQRSTU. Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity Scale, Timing, Understand
Para
of live births
Gravata
of pregnancies
BMI formula
weight (kg) / height (m) squared
Average oral temp
37 degrees c
average pulse rate
60-100
Average respiration rate
10-20
Average blood pressure
120/80
What can high bp lead to?
Heart failure, left ventricular hypertrophy, stroke, ischemic attack, chronic kidney disease, peripheral arterial disease, retinopathy
Ausculatory gap
silent interval that may be present between systole and diastole
Orthostatic hypertension
Drop in systole of 20 or pulse increase of 20 when changing positions (sit -> stand)
Canthus
corner of eye
caruncle
pink tissue in medial canthus
limbus
dark line surrounding iris
tarsal plate
strips of connective tissue that gives eye shape, contains meibomian glands which secrete oily lubricant
Palpebral conjunctiva
lines eyelids
Bulbar conjunctiva
Overlays eyeball anteriorly
Lacrimal apparatus
Constantly irrigates eye, tears drain into the puncta which drains into nasolacrimal sac which drains into inferior meatus
Sclera
fibrous layer of eye
Choroid
Vascular layer of eye
Retina
nervous layer of eye
What can you see in ophthalmoscope view?
4 sets of retinal vessels, retinal field, optic disc, macula
Optic disc
on the nasal side of retina, where fibers converge to form optic nerve (CNII), blind spot because no receptors
Macula
on the temporal side of the retina, surrounds fovea centralis (point of sharpest vision)
How many extrocular muscles?
4 rectus, 2 oblique
Which cranial nerves innervates the lateral rectus muscle?
CNVI (abducens) and abducts eye
Which CN innervates the superior oblique muscle?
CN IV (trochlear), down and towards nose
Which muscles does CNIII innervate?
Oculomotor, all the muscles except superior oblique and lateral rectus muscle
Visual pathway
light off object –> retina –> optic nerve –> optic chiasm –> optic tract –> optic radiation –> occipital lobe
Images are projected?
upside down and reveresed right to left
Direct pupillary light reflex CNs
subcortical reflex arc (subconscious), afferent link is CNII and efferent link is CNIII
How are infant eyes different?
macula are not fully developed, poorly coordinated eye muscles, less pigmentation in iris
How are elderly eyes different?
Skin loses elasticity, floaters in vitreous humor, lens can’t accomodate as well so vision is blurry
Arcus senilis
degenerative lipid material forms a grey ring around iris
Presbyopia
farsightedness caused by loss of elasticity of lens
Cataracts
lens discolors and thickens, gets cloudy
Glaucoma
increased intraocular pressure damages optic nerve, happens more in men
Macular degeneration
macula degenerates, happens more in women
Strabismus
Test with corneal light reflex, cross eye/lazy eye, diplopia (double vision)
Myopia
nearsighted
Hyperopia
farsighted
Legally blind
20/200
Anisocoria
pupils are different sizes
Entropion
Eyelashes fold in and irritate cornea
Nystagmus
Oscillation of eyes, can be a sign of drug use, test with 6 cardinal positions of gaze
bitemporal hemianopsia
optic chiasm is cut so fibers can’t cross over so visual loss of temporal half of each field
left homonymous hemianopsia
right optic tract is cut/lesion, visual loss involves same half of each eye, in this case the right side of the retina so left temporal vision field and right nasal field are disrupted
AV Nicking
Arterial venous nicking, sign of hypertension, artery and vein cross in eye causing compression of vein
Papilledema
Inflammation of optic disc from increased intracranial pressure, disc is cloudy, usually bilateral, if untreated can lead to blindness
3 main facial muscles
frontalis, temporalis and masseter
CNVII
facial nerve, innervates frontalis, temporalis and masseter, facial expressions
CNV
trigeminal nerve, pain and touch of facial muscles
What are flat nasal labial folds a sign of?
Stroke or bells palsy
What are enlarged parotid glands a sign of?
mumps
Where are the parotid glands?
located in cheeks over mandible
sternoclidomastoid muscle innervation and movement
CNXI (accessory), rotation and flexion of head
trapezius muscle innervation and movement
CNXI (accessory), move shoulders and extend head
preauricular lymph nodes
in front of ears, drain scalp, forehead, ears and eyelid
posterior auricular nodes
behind ears, drains parietal scalp and external ear
occipital nodes
at the base of skull, drains parietal scalp
How to test CNXI?
shrug shoulders and turn head
what is an off center trachea the sign of?
sign of collapsed lung or tumor pushing it off center
what is a bruey in carotid the sign of?
artery is at least 70% occluded
Tonsilor nodes
at angle of jaw, drains tonsils, floor of mouth, posterior palette, thyroid gland
submandibular nodes
drains mucosa of mouth an dlips, tongue, conjunctiva, submaxillary glands
submental glands
drains tongue, floor of mouth, mucosa of mouth and lips
superficial cervical nodes
overlying sternoclidomastoid muscle, drains ear and skin of neck
posterior cervical nodes
drains thyroid, posterior scalp and posterior neck skin
deep cervical nodes
drains thyroid, trachea, posterior scalp and posterior neck skin
superclavicular nodes
closest to heart, right node drains mediastinum/lungs/esophagus, left node drains thorax and abdomen
thyroid gland
isthmus lies over trachea, largest endocrine gland, makes T3 and T4 hormones to regulate cellular metabolism and growth
acromegaly
pituitary gland makes too much growth hormone, enlarged bones
fetal alcohol syndrome
thin upper lip, flat nose, wide eyed
bell’s palsy
peripheral lesion of CNVII (facial), partial facial paralysis
goiter
enlarged thyroid
how often do you need to measure infant’s skull?
ages 0-6, every visit until age 2 and yearly after
anterior fontanel
between frontal and parietal bone, intersection of coronal and metopic sutures, closes 12-18 months, diamond shape
posterior fontanel
triangle shape, sagittal and lamboid sutures, between parietal and occiptial bones, closes 6 weeks - 2 months
what are the 3 layers of skin?
epidermis, dermis and subcutaneous
epidermis
stratefied squamos epithelium, avascular
stratum corneum
part of the epidermis, top protective barrier of keratinized cells, regulates water loss
stratum germinativum
deepest layer that lies closest to dermis where there is active cell generation
dermis
highly vascular, regulates body temperature by dilating/constricting blood vessels, contains sensory fibers and nourishes epidermis, can stretch/contract
subcutaneous/hyperdermis
structures/anchor, loose connective tissue and subcutaneous fat, retains heat/calories/cushion
eccrine sweat glands
regulates body temperature via water secretion, almost everywhere
apocrine sweat glands
deeper, only in axilla, nipples, anogenital area, eyelids, external ear, responds to emotions by secreting fluid with proteins, decomposes to make BO
sebaceous glands
secretes sebum to prevent dry hair and skin, in face and scalp but not in hands and feet
papilla
capillary loop at follicle that provides nourishment
nail is made of?
epidermal cells converted to hard plates of keratin
lunula
new nail growth
pitting in nails is a sign of?
psoriasis
erythema
reddening of skin in patches
vitiligo
loss of color in blotches
acanthosis nigricans
area of dark, velvety discoloration in body folds
mongolian spots
on babies, does not blanch when pressed on, goes away with age, blue/brown
cafe au lait spot
flat, pigmented birthmarks, light brown, only worry if 6 or more
acrocyanosis
persistent blue extremities, usually benign and goes away
cutis marmorata
blue/red veiny pattern when cold, worry for babies b/c they need more O2 when it is cold
comedonal acne
white head or black head
pustular acne
infected red pimple
seborrheic keratosis
scaly, warty, raised growths, not malignant, black or brown
senile lentigines
sun spots/liver spots
diaphoresis
excess sweat
edema causes?
DVT, chronic, venous insufficiency, lymphedema, orthostatic edema, congestive heart failure
mobility
skin’s ease of rising
turgor
skin’s ability to return to place, reflects moisture and elasticity
purulent
pus drainage
serous
yellow-clear serum
serosanguinous
serous + blood
eschar
dead tissue, contains necrotic tissue, black
ecchymosis
bruise
excoriation
scratch
decubitus
lying down ulcer
macule
primary, circumscribed, flat, nonpalpable change in skin color, up to 1 cm, ex. freckles, ptechiae
patch
primary, macule larger than 1 cm, ex. liver spots, mongolian spot
papule
primary, palpable, elevated, circumscribed, solid mass with no fluid inside, up to 1cm
plaque
primary, flat, elevated surface larger than 0.5cm, lots of papules together
nodule
primary, solid, elevated, firm or soft mass less than 1-2cm, can extend deeper into the dermis than a papule, ex. fibroma, intradermal nevi
tumor
primary, solid, elevated firm or soft mass larger than 1-2cm, extend deeper into dermis, can be benign or malignant
lipoma
primary, fatty tumor
hemangioma
primary, pink growth filled with blood
wheal
primary, superficial, raised, red, transient lesion, with somewhat irregular borders due to localized edema, fluid is held diffusely in the tissues, ex. mosquito bite
urticaria
primary, wheals that are super itchy, like hives
vesicle
primary, circumscribed, superficial, elevated cavity containing free fluid, up to 1cm, ex. herpes simplex
bullae
primary, larger vesicle, single chambered, superficial in epidermis, thin walled, larger than 1cm, ex. friction blister
cyst
primary, incapsulated fluid/pus filled cavity in dermis or subcutaneous layer, larger than 1cm, ex. sebaceous cyst
pustule
primary, circumscribed, superficial, elevated cavity, contains turbid fluid (pus), up to 1cm, ex. impitigo, acne
crust
secondary, dried residue of burst vesicle
scaling of tinea pedis
secondary, compact desiccated flakes of skin, dry/greasy, from shedding of dead excess keratin, visible white/silver exfoliation of dermis
fissures
secondary, linear crack with abrupt edges, can extend to dermis
erosion
secondary, superficial, circumscribed loss of epidermis, leaves scooped out shallow depression, moist but no blood, heals w/o scar, stage 2 pressure sores
ulcer
secondary, extends into dermis, may bleed, leaves scar
scar
secondary, fibrous connective tissue
atrophy
secondary, stretch marks, thinning epidermis leads to depressed skin level
lichenification
secondary, thickening/roughening of skin as a result from intense scratching, ex. eczema
annular
circular
confluent
lesions running together
discrete
lesion is alone
grouped
cluster of lesions
gyrate
twisted, coiled
target
lyme disease
polycyclic
circular lesions
zosteriform
along dermatome
petechiae
secondary, flat, red, pin sized macules of blood,
purpura
larger macule/papule of blood, 0.3-1cm, does not blanch
ecchymosis
1cm, non-elevated, rounded/irregular, blue/purple patch
cherry angioma
bright red papule, benign
spider angioma
legs radiating from center, disappears when pressed down, sign of liver disease
telangiectasia
permanently dilated vessels, can be in basal cell carcinomas/nifedi pine
nevus flammeus
port wine stain, present at birth, dilated dermal capillaries, pale pink to purple macules, face & trunk
herpes simplex I
cold sore vesicles, oral
herpes simplex II
genital
varicella
chicken pox
herpes zoster
shingles, on one side of body, can cause deafness/blindness/facial paralysis
skin cancer warning signs
ABCDEE, asymmetry, border, color, diameter, elevation, enlargement
basal cell carcinoma
most common, slow growing, rarely metastisized, translucent, dome-shaped papule with overlying telangiectasia
actinic keratosis
malignant potential, flaky patches
squamous cell carcinoma
invasive malignancy, can arise from actinic keratosis, heals/breaks down
alopecia areata
non-scarring hair loss, sharply defined area, usually immunological
hirsution
excessive female hairiness
clubbing
nails rounded, angle flattens out, can be a sign of lung disease or cancer
CNI
olfactory, smell
CNII
optic
CNIII
oculomotor
CNIV
trochlear
CNV
trigeminal
CNVI
abducens
CNVII
facial
CNVIII
vestibulocochlear
CNIX
glossopharyngeal
CNX
vagus
CNXI
accessory
CNXII
hypoglossal
Middle ear ossicles
malleus, incus, stapes
otosclerosis
abnormal bone growth in the middle ear that causes hearing loss
presbycusis
age-related hearing loss
conductive hearing loss
mechanical dysfunction of external or middle ear, can be a partial loss
sensorineural loss
damage to either inner ear, CNVIII or auditory cerebral cortex, can be from age or ototoxic drugs
What can cause vertigo or staggering gait?
inflammed labrynth of the ear
Tinnitus
ear ringing, associated with nerve damage
weber test
512 fork at midline of head, laterlizing midline is normal
weber test for conductive loss
lateralizes to bad ear because air doesn’t influence hearing so all through the bone
weber test for sensorineural loss
no sound in bad ear, louder in left ear
Rinne test
press tuning for to mastoid process, move away until pt can’t hear, move fork to outside of ear
rinne test for conductive loss
AC
rinne test for sensorineural loss
AC>BC but in a smaller ratio in the or no sound in bad ear, AC>BC in normal ratio
what can cause sensorineural loss
asprin, antibiotics, diuretics, aging, loud noises
what is pain in mastoid process a sign of?
otitis media, mastoiditis
tragus pain is a sign of?
otitis externa (swimmers ear)
What does impacted cerumen cause?
partial deafness, tinnitus, dizziness
exostosis
formation of new bone outcropping, seen in swimmers and surfers, can cause infections, pain, plugging, hearing loss
otitis externa
scaling, crusting, inflammation, discharge in external canal, painful tragus, swimmers ear
serous otitis media
tympanic membrane is retracted and decreased mobility, thin serous fluid
bacterial otitis media
red & inflammed, pus
perforated typmanic membrane
white scarring tightens membrane
most common site for nosebleeds?
Kiesselbach region
which sinus is not present at birth
frontal
which gland opens to stenson’s duct
parotid
which gland opens to wartons duct
submandibular
what can cause nasal polyps
allergies
which gland has many openings
sublingual
are fordyce spots and torus palatinus normal
yes (white spots on tongue and ridge on mouth)
which side does the tongue deviate to (abnormal)
paralyzed side
what test is done for CNXII
hypoglossal, stick tongue out
what test is done for CNX
vagus, see that uvula rises
viral pharyngitis
red scratchy throat
bacterial pharyngitis
red scratchy throat with exudate, fever, enlarged cervical nodes, probably strep a or mono
