Exam 2 Concepts Flashcards
organ system issues that manifest in skin, hair, and nail problems
respiratory
cardiac
dehydration
signs of respiratory dysfunction
C ap refill slow
R ounded nails “clubbing”
A zul skin “cyanosis”
P allor
cyanosis
LATE sign of respiratory distress that does not always occur
some pts constantly cyanotic d/t large number of deoxygenated RBCs
clubbing
REVERSIBLE bulging of distal fingers and nail beds unless pt suffers from chronic dz (irreversible)
associated w/respiratory and cardiac dysfunction, neoplasms (cancer)
capillary refill
color should return in 1-2sec
slow indicates respiratory or cardiac dysfunction
signs of cardiac dysfunction
T emperature cool
E dema
R espiratory signs
D iaphoresis “cold sweat”
edema scale
1+ mild pitting
2+ moderate pitting
3+ deep pitting
4+ very deep pitting
signs of dehydration
dry mucous membranes
poor skin turgor
jaundice
yellowing of the hard/soft palate, sclera
indicates liver dysfunction, blood disorders (ex. sickle cell dz)
malignant skin lesions
A symmetry B order irregularity C olor variation D iameter > 6mm E levation or evolution
“spot ugly duckling”
annular skin lesion
ring-shaped
confluent skin lesion
merging together
discreet skin lesion
distinct, separate
gyrate skin lesion
coiled, snakelike
grouped skin lesion
clustered
linear skin lesion
line, stripe
target skin lesion
resembles eye iris, concentric rings
zosteriform skin lesion
linear along nerve route
polycyclic skin lesion
annular grown together
pressure ulcer stages
1 intact skin erythematous; does not turn white w/pressure
2 loss of epidermis or dermis; red-pink shallow wound
3 subcutaneous tissue visible’ resembles crater
4 exposed muscle, tendon, or bone
assessing head size
normocephalic
microcephalic
macrocephalic
fontanels
soft spots
- posterior closes by 2 months
- anterior closes by 2 yrs
if sunken = dehydration
if bulging = bleeding d/t trauma
“2,2,2”
faces of fetal alcohol syndrome
smooth upper lip
thin upper lip
short eye openings
assymetrical facial drooping
may be sign of a stroke
trachea assessment
normally midline
deviation may be d/t neoplasm, goiter, or TN pnuemothorax from lung puncture/collapse
thyroid assessment
note size, consistency, symmetry, presence of nodules
lymph node assessment
if palpable, normally moveable, discreet, soft, and nontender
enlarged or tender LNs may signify infection or cancer
lymphadenopathy
infection: bilateral enlarged, warm, tender, freely moveable LNs
cancer: unilateral >3cm enlarged, nontender, matted, fixed
eye assessment
inspect: sclera, conjunctivae, pupil sz/shape pupillary light reflex confrontation test (#s) extraocular muscles corneal light reflex red reflex
assessment of ear
inspect
whisper test
otoscopic exam: tympanic membrane pearly/translucent, cone of light towards chin
sinuses
frontal
maxillary
ethmoid
sphenoid
tonsil scale
4+ “kiss” each other
3+ touch uvula
2+ halfway to uvula
1+ normal
should be pink
assessment of sinuses
palpate for tenderness
indication of sinus infection
(GAS) group A strep
sore throat fever over 100.4F no cough tonsillar exudate cervical lymphadenopathy
untreated may cause rheumatic fever or neuropsych syndromes
oral kaposi sarcoma
oral cancer which typically those w/decreased immune systems;elderly and those w/AIDS most common
sydenham’s chorea
form of REVERSIBLE jerky involuntary movements associated w/untreate rheumatic fever/GAS
normal breast assessment findings
cyclic pain slight size assymetry bilateral network of veins non-recent nipple inversion firm transverse ride of tissue in lower quadrants
breast findings associated w/cancer
dimpling
fixation
peau d’orange “orange peel”
recent nipple inversion
lung anatomy
R lung has two main bronchi; L has one
R has three lobes; L has two
lung assessment
anterior mostly upper lobes
posterior mostly lower lobes
inspection
tactile fremitus “99”
chest percussion
ascultation side to side
abnormal trunk inspection
barrel chest pectus escavatum pectus carinatum scoliosis kyphosis
abnormal respiratory patterns
hyperventilation
cheyne-stokes
biot
tachypnea
signs of respiratory distress
accessory muscles grunting head bobbing nasal flaring retractions tachypnea tripod positions (forward, hand on knees)
heart assessment
point of maximal impulse
cardiac thrills and heaves
auscultation
heart auscultation areas
2nd intercostal L aortic, R pulmonic
3rd intercostal Erb’s point
5th intercostal L tricuspid, R (midclavicular) mitral
S1___systole___S2___diastole___
heart murmurs
valves trouble opening = stenosis
valves trouble closing = regurgitation/insufficiency
abnormal heart sounds
S4(before S1) “stiff as a board”; lub lub dub
S3 (after S3) “need to pee” d/t fluid overload
signs of heart failure
dilated pupils pale, grey, or cyanotic skin cool, moist skin jugular vein distention low BP ascites decreased urine output
potential blood vessel problems
arterial insufficiency
venous insufficiency - venous valves bust; blood goes back down instead of toward heart
deep vein thrombosis
signs of arterial insufficiency
diminished pulses cool, pale skin thin, shiny skin loss of hair on lower legs thick-ridged nails
signs of venous insufficiency
palpable pulses
edematous (chronic) or swollen (acute)
warm, brown (chronic) or red (acute) skin
thickened skin
abdomen assessment
inspection
auscultation
percussion
palpation
abdomen auscultation
listen w/diaphragm for 15-20sec in one quadrant; 5mins if no sounds heard
listen w/bell for bruits “whooshing”; renal stenosis common
RUQ organs
liver right kidney gallbladder pancreas colon
LUQ organs
spleen left kidney stomach pancreas colon
RLQ organs
appendix
colon
small intestine
LLQ organs
colon
small intestine
