Exam 2 Flashcards
CN I
Olfactory
- smell
CN II
Optic
- sight
CN III
Oculomotor
- eyeball movement: MR, IR, SR, IO
- movement of upper eyelid: LP
- pupillary light reflex
CN IV
Trochlear
- eyeball movement: superior oblique
CN V
Trigeminal
- Opthalmic: facial sensation/pupillary dilation
- Maxillary: facial sensation
- Mandibular: chewing/facial sensation
CN VI
Abducens (6 Abs)
- eyeball movement: lateral rectus
CN VII
Facial
- taste: anterior of tongue
- facial expression/eyelid closing
- lacrimation
- salivation
CN VIII
Vestibulocochlear
- hearing: cochlea
- balance: vestibular apparatus
CN IX
Glossopharyngeal
- sensation from posterior 1/3 of tongue, tonsils middle ear, pharynx
- stylopharyngeus muscle
- salivation
CN X
Vagus
- swallowing
- elevation of palate
- talking
- coughing
- gag reflex
- heart rate
- GI peristalsis
- sweating
- vasovagal synope
- peripheral chemoceptors
CN XI
Accessory
- head turning: SCM
- shrugging: trapezius
CN XII
Hypoglossal
- most muscles of tongue (except palataglasus)
- tongue movement
What to look at when assessing integumentary system?
skin
hair
scalp
nails
Integumentary Assessment Equipment
penlight
gloves
flexible ruler/tape measure
gown/drape to cover the client
What are you looking for when inspecting the skin?
color
odor
integrity
Abnormal findings in skin:
tenderness may indicate….
inflammation
Abnormal findings in skin:
increase moisture
fever or thyroxitoxicosis
Abnormal findings in skin:
decrease moisture
dehydration, myxedema, chronic nepriritis
Abnormal findings in skin:
coarse, thick, dry skin
hypothyroidism
Abnormal findings in skin:
skin more fine-texture
hyperthyroidism
Abnormal findings in skin:
smooth, thin, shiny skin
Arterial Insufficiency
Abnormal findings in skin:
thick, rough skin
venous insufficiency
Abnormal findings in skin:
decreased turgor/tenting
dehydration or normal aging
Abnormal findings in skin:
increase turgor/tension
scleroderma and edema
What are you looking for when inspecting the nails?
color
condition
angle of attachment
presence of focal or generalized abnormalities (ridges/clubbing)
Normal nail angle
160*
abnormal nail angle
> or = 180*
Abnormal findings in nails:
yellow nails
cigarette smoking
fungal infection
psoriasis
Abnormal findings in nails:
very distal band of reddish-pink or brown covering <20%
cirrhosis
disorder causing hypoalbuminemia
Abnormal findings in nails:
distal band of reddish-pink or brown covering 20% to 60% of the nail
renal disease
hypoalbuminemia
Abnormal findings in nails:
green nails (pseudonomas)
infection
Abnormal findings in nails:
white nails (leukonychia)
trauma
liver
cardiovascular
renal disease
Abnormal findings in nails:
black nails
trauma
Abnormal findings in nails:
splinter hemmorhage
bacterial endocarditis
trauma
Abnormal findings in nails:
clubbing
congenital heart disease
cystic fibrosis
chronic pulmonary disease
Abnormal findings in nails:
spooning/concave nail (koilonychia)
severe iron deficiency anemia
Abnormal findings in nails:
separation of nail from the bed (onycholysis)
fungal infection
psoriasis
eczema
following trauma
as allergic response to new products
Abnormal findings in nails:
pitting
psoriasis
What to look for when examining lesions?
size
color
shape
consistency
elevation
location
distribution
configuration
tenderness
fluid
drainage
arise from healthy skin tissue
primary lesion
non-palpable
skin color change
< 1cm
freckles, mole melanoma
Macule
palpable
circuscribed
solid elevation of the skin
<1cm
elevated nevus
psoriasis
Papule
palpable
circumscribed
deep
firm
1-2cm
wart
Nodule
serous fluid-filled
<1cm
blister, herpes simplex, varicella
Vesicle
pus-filled
varied in size
acne
Pustule
solid mass
deep
larger than 1-2cm
epithelioma
Tumor
palpable
irregular borders
edematous
insect bite
Wheal
thinning of the skin
w/loss of the skin furrow
skin is shiny and translucent
arterial insufficiency
Atrophy
results from change in primary lesion
secondary lesion
lost epidermis
moist surface
no bleeding
ruptured vesicle
Erosion
dried blood
serum
pus
scab
Crust
flakes of skin that exfoliate
dandruff, psoriasis, eczema
Scale
linear crack
tinea pedis
Fissure
loss of epidermis and dermis with possible bleeding and scarring
pressure ulcer, venous stasis ulcer
Ulcer
can appear under the fingernails, on the palms and soles of the feet
more common amongst african descent
Melanoma
results from aging changes or blood vessel damage in or near the skin
Vascular lesions
red center radiating with red legs. up to 2cm, possibly raised
Spider Angioma
red, 1-2cm, round, possibly raised
Cherry Angioma
bluish, spider shaped or linear, up to several inches in size
Spider Vein
deep reddish purple, flat
Petechiae (1-3mm)
Purpura (larger than 3mm)
purple fading to green or yellow over time, varies in size, flat
Ecchymosis
raised ecchymosis
Hematoma
have not yet broken through skin
stage 1 pressure ulcers
have a break in the top 2 layers of skin
stage 2 pressure ulcers
affect the top 2 layers of skin as well as fatty tissue
stage 3 pressure ulcers
are deep wounds that may impact muscle, tendons, ligaments, and bone
stage 4 pressure ulcers
diaper dermatitis
intertrigo
impetigo
atopic dermatitis (eczema)
examples of skin lesions in CHILDREN
primary contact dermatitis
tinea pedis (ringworm of the foot)
psoriasis
labial herpes simplex (cold sores)
examples of skin lesions in ADULTS
lentigines (liver spots)
seborrheic keratosis
dermatosis papulosa nigra (tag-like lesions)
acrochordons (skin tags)
sebaceous hyperplasia
examples of skin lesions in OLDER ADULTS
AVPU Scale
A = Alert
V = Verbal stimulus response
P = Pain stimulus response
U = Unresponsive
assigns points according to the client’s degree of alertness and response to verbal and painful stimulation
AVPU Scale
Hypertrophic scarring caused by excess collage formation
Keloids
coin or oval-shaped
nummular eczema
round/oval
lesions that remain separate and apart
common to many skin disorders
moles
discrete
lesions that are grouped or clustered
herpes simplex
grouped
lesions that run together or are confluent
common in childhood disease
rubella
confluent
lesions arranged in lines are common with contact dermatitis resulting from poison ivy or herpes zoster
linear
ring-shaped lesions
may be ringworm
annular/circular
lesions arranged in partial rings, or arcs, occur in syphilis
arciform
a bull’s eye lesion, or round lesion with central clearing
typical of erythema multiforme and lyme disease
iris
meshlike pattern as in lichen planus
reticular
lesions have serpentine configuration
as in gyrate erythema
gyrate
coalesced, concentric circles, such as in urticaria
polycyclic
lesions distributed over entire body
such as urticaria from allergic reactions
hives, varicella (chicken pox)
diffuse/generalized
lesions that are sparsely distributed
seborrheic keratosis (non-cancerous, benign skin growth)
scattered
lesions in a very limited, discrete area
location may indicate contact w/allergen or wheal from insect bite
localized
confined to a specific body area
tinea capitis (fungal infection)
pityriasis rosea (skin rash)
regional
(head, torso)
psoriasis
extensor surfaces
intertrigo
flexor surfaces
herpez zoster (shingles)
dermatone
herpes simplex virus type 2
pediculosis pubis
dermatome
(hairy areas)
contact dermatitis
diaper rash
intertrigo (erythema and scaling of body folds)
intertriginous areas
actinic keratosis
sun-exposed areas
indications of PALLOR
anemia
shock
lack of blood flow
indications of CYANOSIS
hypoxia
impaired venous return
indications of JAUNDICE
liver dysfunction
red blood-cell destruction
indications of ERYTHEMA
inflammation
localized vasodilation
sun exposure
rash
elevated body temperature
accumulation of fluid in the tissues
most often from direct trauma or impaired venous return
Edema
trace, 2mm, rapid skin response
pitting edema 1+
mild, 4mm, 10-15 sec skin response
pitting edema 2+
moderate, 6mm, prolonged skin response
pitting edema 3+
Crossed eye
Strabismus
Dancing eyes
Twitching eyes or flutter during field vision test
Nystagmus
Bulging eyes
Exophthalmos
Expected findings of neck
Muscles of the neck symmetric
Shoulders equal in height and with average muscle mass
ROM:
Flexion
Lateral flexion
Hyperextendion
How to maintain skin integrity
Adequate nutrition and hydration
Keep clean skin and dry
Apply moisturizer if prescribed