Exam 2 HA Flashcards
How to assess for skin turgor
dorsal side of hand or the chest/below clavicle for elderly
tool used to assess pt’s risk of developing pressure ulcers; higher score is lower risk; 18 or higher = pt not at risk
six criteria each rated on a scale that ranges from 1 – 4 (sensory perception, moisture, activity, mobility, nutrition, and friction/shear)
Braden scale
ABCDE of Melanoma detection
-Asymmetric
-Borders (irregular)
-Color (coffee, multicolor, blue, green)
-Diameter (more than 6mm aka bigger than pencil erase)
-Evolution (change is bad)
impaired skin integrity means greater risk of what?
infection so keep an eye out of s/s like purulent drainage, fever, rash
what is part of normal skin aging?
decreased collagen/ decreased elastin (wrinkly/sagging skin), decreased redistribution of subcutaneous fat from extremities to central part of the body (pot belly w/ thin extremities) which causes ecchymosis aka bruising easily
these are freckles, flat, less than 1 cm
Macules
these are moles, less than 1cm and raised
Nevi
these are raised, greater than 1cm
Nodules
This is flat, greater than 1cm
patch
refers to a pattern of skin lesions that resemble the distribution of herpes zoster (shingles), distributed along dermatome, specific area of skin that is innervated by a single spinal nerve root
*unilateral on one side of body
*vesicular (blister-like) rash, serous fluid
Zosteriform
type of rash that is clear/blister like appearance
vesicular rash
clear/slightly yellow tinged fluid filled blisters less than 1cm (small!)
aka serous fluid filled vesicles
chicken pox
bull’s eye rash, typically on torso
Lyme disease (vector borne disease aka from deer tick)
fibrous tissue replacement, resulting in enlarged scar (overgrowth)
keloid
How to assess hair
inspect:
-color
-distribution
-texture
-lesions
-nits (empty egg cases-lice)
How to assess nails (abnormalities)
-Clubbing d/t chronic hypoxia to distal fingers (pts w/ COPD, emphysema, congestive heart failure)
-Half-and-half nails d/t chronic renal failure (proximal white, distal brown)
-Beau’s line d/t slowed or halted nail growth (w/ deep horizontal lie) in response to illness, physical trauma, or poisoning
-Longitudinal ridging d/t aging
-Koilonychia (spoon-like indentation) d/t trauma, iron deficiency aka hemochromatosis (may be normal in infants) or anemia .. nail is lifted along edgers, indented near center
-Pitted nails d/t lesions from psoriasis, crating on nail bed
-Onycholysis: nail plate and nail bed separation d/t trauma, fungal infections, topical irritants, psoriasis, sublingual neoplasms or warts
-Yellow nails d/t lung disorders or lymphedema
-Dark longitudinal streaks: often normal in dark-skinned patients
-Splinter hemorrhages d/t damaged capillaries supplying the nail matrix caused by micro emboli
this nail abnormality is d/t chronic hypoxia to distal fingers (pts w/ COPD, emphysema, congestive heart failure)
clubbing
this nail abnormality is d/t chronic renal failure (proximal white, distal brown)
half and half nails
this nail abnormality is d/t slowed or halted nail growth (w/ deep horizontal line) in response to illness, physical trauma, or poisoning
Beau’s line
this nail abnormality is d/t aging
Longitudinal ridging
this nail abnormality is spoon-like indentation where nail is lifted along edgers, indented near center d/t trauma, anemia, iron deficiency aka hemochromatosis.. may be normal in infants
Koilonychia
this nail abnormality is d/t lesions from psoriasis, crating on nail bed
pitted nails
this nail abnormality is when the nail plate and nail bed has separation d/t trauma, fungal infections, topical irritants, psoriasis, sublingual neoplasms or warts
Onycholysis
this nail abnormality is d/t lung disorders or lymphedema
yellow nails
this nail abnormality is often normal in dark-skinned patients
Dark longitudinal streaks
this nail abnormality is d/t damaged capillaries supplying the nail matrix caused by micro emboli
Splinter hemorrhages
sweat glands
-Eccrine: sweat secretion, assist in thermoregulation
-Apocrine: located in axillae and genital areas, active during puberty- the stench! decreases w/ age
-Sebaceous: secrete sebum (oily substance that hydrates skin), decrease w/ age
sweat gland that is responsible for sweat secretion, assists in thermoregulation
Eccrine sweat gland
sweat gland that is located in axillae and genital areas, active during puberty - the stench! decreases w/ age
Apocrine sweat gland
secrete sebum (oily substance that hydrates skin), decrease w/ age
Sebaceous sweat gland
how to assess the abdomen?
- inspect (for skin abnormalities, pulsations, masses etc)
- auscultate
- percuss
- palpate
(lungs is palpate then percuss)
What part of the abdomen do you inspect first?
RLQ
what to do first in head/cervical spine injury
immobilize cervical spine until scan show no fx
how to assess pain?
OLDCARTS (onset, location, duration, characteristics, aggravating factors, relieving factors, time. severity)
what system to check if C4 or above injury
respiratory
How to assess the thyroid
- thyroid cartilage (at top)
- cricoid cartilage (aka Adam’s apple)
- thyroid gland (at bottom)
where is the thyroid gland?
below the thyroid cartilage and cricoid cartilage (Adams apple)
abnormal lymph nodes vs normal lymph nodes
normal = should not be palpable unless sick
abnormal = hard (firm), immobile (fixed), greater than 1cm
s/s of hypothyroidism
-weight gain
-fatigue
-cold
-constipation
-large neck goiters
-dysthymia (depression)
-dry skin
-brittle nails
-low b/p, low HR
s/s of hyperthyroidism
-weight loss
-heat intolerance
-tachy (high HR), high bp
-warm aka heat intolerance
-oily skin/hair
-anxious
-energetic
-hyper
2 responsibilities of the lymph node system?
- immunity
- transport fluid back into circulation
how to access the thyroid
feel for it! have pt swallow/drink water
pre auricular lymph node
drains ear, possible ear infection if inflammed
cervical lymph node (anterior cervical)
drains throat, may tonsil infection
submental lymph node
near chin, so might have jaw or teeth infection
what is peripheral vascular disease
-change in arterial blood flow d/t plaque
-resulting in coolness, paleness, lower HR, paresthesia (tingling), hypoesthesia (numb)
this test tests for collateral circulation of radial & ulnar arteries, performed prior to drawing ABGs or insertion of an arterial line
Allen Test (fist test)
pooling of blood in the veins often d/t inadequate venous return
venous stasis
(this can cause edema aka swelling, shiny skin, no hair growth, red/brown color from old blood)
what is a pt at risk for if venous stasis occurs?
at risk for impaired skin integrity which can cause ULCERS
**due to lack of O2 rich blood flow to capillaries in tissue (slow death of tissues)
s/s of venous stasis?
swelling/edema in legs, shiny skin, no hair growth, red/brown color due to old blood
pt can also get ulcers due to impaired skin integrity
difference between Dysphagia vs Odynophagia
Odynophagia - painful swallowing
dysphagia - difficulty swallowing
what is it called when pt has difficulty swallowing
dysphagia
what is it called when pt has pain swallowing
Odynophagia
What is s/s of a DVT?
unilateral pain, edema aka swelling, erythema aka red, heat… immediately call provider!
detecting changes in blood flow (color & temp changes)
if less than 3 seconds, this Is good.
if greater, then there is impaired circulation
capillary refill
6 Ps for arterial occlusion
- Pain
- pallor
- poikilothermia
- paresthesia
- pulselessness
- paralysis
coolness of an extremity may indicate this
other s/s include: pain, paresthesia (tingly), pallor (pale)
arterial occlusion
s/s of a PE resulting from a DVT
acute dyspnea (SOB), chest pain, tachycardia (high HR), diaphoresis (sweating), anxiety
difference between DVT vs acute arterial occlusion
DVT- clot that forms in vein
erythema (red)
acute arterial occlusion- blockage in peripheral artery impacting flow to limbs
pallor (pale)
this is the result of a DVT, when the DVT breaks free & starts traveling which could lead to a PE (to lung) or MI (to heart) or stroke (to brain)
VTE (venous thromboembolism)
a pt is having right abdominal pain that radiates to the right scapula, which organ is a concern?
gallbladder
blockage in peripheral artery impacting flow to limbs, contains the 6 Ps
acute arterial occlusion
6 Ps:
1. Pain
2. pallor
3. poikilothermia
4. paresthesia
5. pulselessness
6. paralysis
enlarged liver (hepatomegaly) can be due to this
Cirrhosis
(due to hepatitis or chronic alcoholism)
70% chance of death if pt has this
PE (pulmonary embolism) aka blood clot travels from legs to the lungs
if cap refill is slow, you might have this
cold fingers
so do further investigation! warm them, check temp & vitals
how to palpate the abdomen
start in RLW then go clockwise
RLQ -> RUQ -> LUQ ->LLQ
unless pt has pain then palpate that quadrant LAST! (start wherever you would end up in last aka painful quadrant)
enlarged liver d/t cirrhosis
hepatomegaly
enlarged spleen d/t EBV aka Epstein-Barr Virus (mono)
splenomegaly
sign of aging when it comes to GI
decreased peristalsis (movement during digestive process) leading to constipation
bowel loop (or loop of bowel) protrudes through weak muscles, most common weak muscle is abdominal muscle
hernia
why do we test for ascites (extra fluid in abdomen)
test for a fluid wave aka ascites bc it is commonly found in pts w/ cirrhosis secondary to chronic alcoholism.
**Only found in pts w/ cirrhosis due to alcoholism!!! Not gallbladder or appendicitis
these drain from the area above it
lymph nodes
how long do you have to listen in abdomen prior to stating no bowel sounds
5 mins in each quadrant so 20 minutes!
(you should hear 5-30 bowel sounds in each quadrant bc this represents movement of fluids/food)
where is the Dorsalis pedis pulse
top of foot lateral to extensor longus tendon
pinpoint of cervical/spine
C7
Need to assess respiratory first if this area is injured
C4 & above
population of ppl w/ gallbladder disease
(4 Fs) : Female, Fat, over Forty, Fertile
risk factors for colorectal cancer (non modifiable & modifiable)
non modifiable- genetics, age, family hx, gender (males are at higher risk)
modifiable- diet: high fat/low fiber is bad, lack of exercise is bad, smoking is bad, EtOH use is bad
positive (+) Murphy sign means what?
pt had sharp tenderness/pain & gasps to breathe when deep palpation of the liver which sits on the gallbladder
**cholecystitis could be a problem at this area of abdomen
light vs deep palpation of abdomen
light: 1-2cm
deep: 3-4cm
what should you hear when you percuss over the abdomen
dull - over bone, solid area aka organ, or fluid
tympany - normal areas
what does pain/tenderness when whacking on the back of a pt (CVA test aka costovertebral angle) identify?
pyelonephritis (kidney infection) or nephrolithiasis (kidney stones)
normal assessment for lower extremities
Skin intact, warm/pink, pedal pulse palpable 2+, no pitting
what can lead to odynophagia (painful swallowing) or dysphagia (difficulty swallowing)
GERD, Parkinson’s disease, hiatal hernia, stroke pts
largest blood vessel
aorta
pitting vs non pitting edema?
what’s the scale?
pitting- leaves fingerprint
non pitting- does not leave mark
pitting scale:
1+ slight pitting, 2mm depression
2+ increased pitting, 4mm depression
3+ deeper pitting, 6mm depression, obvious edema of extremity
4+ severe pitting, 8mm depression, extremity appears very edematous
elderly are at risk of this due to lack of sweat glands
hyperthermia & hypothermia
What is McBurney’s pt used to assess?
appendicitis
(palpate RLQ near umbilici & anterior ileac crest… if pain then positive for appendicitis)
what are the 2 signs to test for appendicitis?
-Psoas sign: place hand right above pt’s right knee and ask them to raise that thigh against your hand, extend the right leg at the hip to stretch the iliopsoas muscle (if painful then positive for appendicitis)
-Obturator sign: flex the pt’s right thigh at the hip w/ the knee bent and rotate the leg internally at the hip stretching the internal obturator muscle (if painful then positive for appendicitis)
define skin of the elderly
dry, no hair, shiny due to poor venous blood flow
signs of arterial insufficiency
pale, cold, pulseless or thready pulse leg
this might be a sign of an aortic aneurism (ruptured aorta)
Pain in the epigastric area that radiates to the scapula with SOB aka dyspnea , sharp and stabbing pain!
arterial insufficiency s/s
pale, cold, pulseless leg
venous insufficiency s/s
dark brown leg due to old blood, warm and pink leg
