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NUR 310 Health Assessment > Exam 2 Concepts > Flashcards

Exam 2 Concepts Flashcards

1
Q

organ system issues that manifest in skin, hair, and nail problems

A

respiratory
cardiac
dehydration

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2
Q

signs of respiratory dysfunction

A

C ap refill slow
R ounded nails “clubbing”
A zul skin “cyanosis”
P allor

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3
Q

cyanosis

A

LATE sign of respiratory distress that does not always occur

some pts constantly cyanotic d/t large number of deoxygenated RBCs

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4
Q

clubbing

A

REVERSIBLE bulging of distal fingers and nail beds unless pt suffers from chronic dz (irreversible)

associated w/respiratory and cardiac dysfunction, neoplasms (cancer)

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5
Q

capillary refill

A

color should return in 1-2sec

slow indicates respiratory or cardiac dysfunction

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6
Q

signs of cardiac dysfunction

A

T emperature cool
E dema
R espiratory signs
D iaphoresis “cold sweat”

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7
Q

edema scale

A

1+ mild pitting
2+ moderate pitting
3+ deep pitting
4+ very deep pitting

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8
Q

signs of dehydration

A

dry mucous membranes

poor skin turgor

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9
Q

jaundice

A

yellowing of the hard/soft palate, sclera

indicates liver dysfunction, blood disorders (ex. sickle cell dz)

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10
Q

malignant skin lesions

A 
A  symmetry
B  order irregularity
C  olor variation
D  iameter > 6mm
E  levation or evolution

“spot ugly duckling”

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11
Q

annular skin lesion

A

ring-shaped

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12
Q

confluent skin lesion

A

merging together

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13
Q

discreet skin lesion

A

distinct, separate

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14
Q

gyrate skin lesion

A

coiled, snakelike

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15
Q

grouped skin lesion

A

clustered

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16
Q

linear skin lesion

A

line, stripe

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17
Q

target skin lesion

A

resembles eye iris, concentric rings

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18
Q

zosteriform skin lesion

A

linear along nerve route

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19
Q

polycyclic skin lesion

A

annular grown together

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20
Q

pressure ulcer stages

A

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

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21
Q

assessing head size

A

normocephalic
microcephalic
macrocephalic

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22
Q

fontanels

A

soft spots

  1. posterior closes by 2 months
  2. anterior closes by 2 yrs

if sunken = dehydration
if bulging = bleeding d/t trauma

“2,2,2”

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23
Q

faces of fetal alcohol syndrome

A

smooth upper lip
thin upper lip
short eye openings

24
Q

assymetrical facial drooping

A

may be sign of a stroke

25
Q

trachea assessment

A

normally midline

deviation may be d/t neoplasm, goiter, or TN pnuemothorax from lung puncture/collapse

26
Q

thyroid assessment

A

note size, consistency, symmetry, presence of nodules

27
Q

lymph node assessment

A

if palpable, normally moveable, discreet, soft, and nontender

enlarged or tender LNs may signify infection or cancer

28
Q

lymphadenopathy

A

infection: bilateral enlarged, warm, tender, freely moveable LNs
cancer: unilateral >3cm enlarged, nontender, matted, fixed

29
Q

eye assessment

A 
inspect: sclera, conjunctivae, pupil sz/shape
pupillary light reflex
confrontation test (#s)
extraocular muscles
corneal light reflex
red reflex
30
Q

assessment of ear

A

inspect
whisper test
otoscopic exam: tympanic membrane pearly/translucent, cone of light towards chin

31
Q

sinuses

A

frontal
maxillary
ethmoid
sphenoid

32
Q

tonsil scale

A

4+ “kiss” each other
3+ touch uvula
2+ halfway to uvula
1+ normal

should be pink

33
Q

assessment of sinuses

A

palpate for tenderness

indication of sinus infection

34
Q

(GAS) group A strep

A 
sore throat
fever over 100.4F
no cough
tonsillar exudate
cervical lymphadenopathy

untreated may cause rheumatic fever or neuropsych syndromes

35
Q

oral kaposi sarcoma

A

oral cancer which typically those w/decreased immune systems;elderly and those w/AIDS most common

36
Q

sydenham’s chorea

A

form of REVERSIBLE jerky involuntary movements associated w/untreate rheumatic fever/GAS

37
Q

normal breast assessment findings

A 
cyclic pain
slight size assymetry
bilateral network of veins
non-recent nipple inversion
firm transverse ride of tissue in lower quadrants
38
Q

breast findings associated w/cancer

A

dimpling
fixation
peau d’orange “orange peel”
recent nipple inversion

39
Q

lung anatomy

A

R lung has two main bronchi; L has one

R has three lobes; L has two

40
Q

lung assessment

A

anterior mostly upper lobes
posterior mostly lower lobes

inspection
tactile fremitus “99”
chest percussion
ascultation side to side

41
Q

abnormal trunk inspection

A 
barrel chest
pectus escavatum
pectus carinatum
scoliosis
kyphosis
42
Q

abnormal respiratory patterns

A

hyperventilation
cheyne-stokes
biot
tachypnea

43
Q

signs of respiratory distress

A 
accessory muscles
grunting
head bobbing
nasal flaring
retractions
tachypnea
tripod positions (forward, hand on knees)
44
Q

heart assessment

A

point of maximal impulse
cardiac thrills and heaves
auscultation

45
Q

heart auscultation areas

A

2nd intercostal L aortic, R pulmonic
3rd intercostal Erb’s point
5th intercostal L tricuspid, R (midclavicular) mitral

S1___systole___S2___diastole___

46
Q

heart murmurs

A

valves trouble opening = stenosis

valves trouble closing = regurgitation/insufficiency

47
Q

abnormal heart sounds

A

S4(before S1) “stiff as a board”; lub lub dub

S3 (after S3) “need to pee” d/t fluid overload

48
Q

signs of heart failure

A 
dilated pupils
pale, grey, or cyanotic skin
cool, moist skin
jugular vein distention
low BP
ascites
decreased urine output
49
Q

potential blood vessel problems

A

arterial insufficiency

venous insufficiency - venous valves bust; blood goes back down instead of toward heart

deep vein thrombosis

50
Q

signs of arterial insufficiency

A 
diminished pulses
cool, pale skin
thin, shiny skin
loss of hair on lower legs
thick-ridged nails
51
Q

signs of venous insufficiency

A

palpable pulses
edematous (chronic) or swollen (acute)
warm, brown (chronic) or red (acute) skin
thickened skin

52
Q

abdomen assessment

A

inspection
auscultation
percussion
palpation

53
Q

abdomen auscultation

A

listen w/diaphragm for 15-20sec in one quadrant; 5mins if no sounds heard

listen w/bell for bruits “whooshing”; renal stenosis common

54
Q

RUQ organs

A 
liver
right kidney
gallbladder
pancreas
colon
55
Q

LUQ organs

A 
spleen
left kidney
stomach
pancreas
colon
56
Q

RLQ organs

A

appendix
colon
small intestine

57
Q

LLQ organs

A

colon

small intestine

NUR 310 Health Assessment (6 decks)

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