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Health Assessment > Exam 2 HA > Flashcards

Exam 2 HA Flashcards

1
Q

How to assess for skin turgor

A

dorsal side of hand or the chest/below clavicle for elderly

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2
Q

tool used to assess pt’s risk of developing pressure ulcers; higher score is higher risk; 18 or higher = high risk….

six criteria each rated on a scale that ranges from 1 – 4 (sensory perception, moisture, activity, mobility, nutrition, and friction/shear)

A

Braden scale

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3
Q

ABCDE of Melanoma detection

A

-Asymmetric

-Borders (irregular)

-Color (coffee, multicolor, blue, green)

-Diameter (more than 6mm aka bigger than pencil erase)

-Evolution (change is bad)

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4
Q

impaired skin integrity means greater risk of what?

A

infection so keep an eye out of s/s like purulent drainage, fever, rash

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5
Q

what is part of normal skin aging?

A

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

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6
Q

these are freckles, flat, less than 1 cm

A

Macules

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7
Q

these are moles, less than 1cm and raised

A

Nevi

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8
Q

these are raised, greater than 1cm

A

Nodules

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9
Q

This is flat, greater than 1cm

A

patch

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10
Q

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

A

Zosteriform

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11
Q

type of rash that is clear/blister like appearance

A

vesicular rash

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12
Q

clear/slightly yellow tinged fluid filled blisters less than 1cm (small!)
aka serous fluid filled vesicles

A

chicken pox

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13
Q

bull’s eye rash, typically on torso

A

Lyme disease (vector borne disease aka from deer tick)

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14
Q

fibrous tissue replacement, resulting in enlarged scar (overgrowth)

A

keloid

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15
Q

How to assess hair

A

inspect:
-color
-distribution
-texture
-lesions
-nits (empty egg cases-lice)

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16
Q

How to assess nails (abnormalities)

A

-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

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17
Q

this nail abnormality is d/t chronic hypoxia to distal fingers (pts w/ COPD, emphysema, congestive heart failure)

A

clubbing

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18
Q

this nail abnormality is d/t chronic renal failure (proximal white, distal brown)

A

half and half nails

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19
Q

this nail abnormality is d/t slowed or halted nail growth (w/ deep horizontal line) in response to illness, physical trauma, or poisoning

A

Beau’s line

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20
Q

this nail abnormality is d/t aging

A

Longitudinal ridging

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21
Q

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

A

Koilonychia

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22
Q

this nail abnormality is d/t lesions from psoriasis, crating on nail bed

A

pitted nails

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23
Q

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

A

Onycholysis

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24
Q

this nail abnormality is d/t lung disorders or lymphedema

A

yellow nails

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25
Q

this nail abnormality is often normal in dark-skinned patients

A

Dark longitudinal streaks

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26
Q

this nail abnormality is d/t damaged capillaries supplying the nail matrix caused by micro emboli

A

Splinter hemorrhages

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27
Q

sweat glands

A

-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

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28
Q

sweat gland that is responsible for sweat secretion, assists in thermoregulation

A

Eccrine sweat gland

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29
Q

sweat gland that is located in axillae and genital areas, active during puberty - the stench! decreases w/ age

A

Apocrine sweat gland

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30
Q

secrete sebum (oily substance that hydrates skin), decrease w/ age

A

Sebaceous sweat gland

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31
Q

how to assess the abdomen?

A
  1. inspect (for skin abnormalities, pulsations, masses etc)
  2. auscultate
  3. percuss
  4. palpate

(lungs is palpate then percuss)

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32
Q

What part of the abdomen do you inspect first?

A

RLQ

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33
Q

what to do first in head/cervical spine injury

A

immobilize cervical spine until scan show no fx

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34
Q

how to assess pain?

A

OLDCARTS (onset, location, duration, characteristics, aggravating factors, relieving factors, time. severity)

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35
Q

what system to check if C4 or above injury

A

respiratory

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36
Q

How to assess the thyroid

A
  1. thyroid cartilage (at top)
  2. cricoid cartilage (aka Adam’s apple)
  3. thyroid gland (at bottom)
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37
Q

where is the thyroid gland?

A

below the thyroid cartilage and cricoid cartilage (Adams apple)

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38
Q

abnormal lymph nodes vs normal lymph nodes

A

normal = should not be palpable unless sick

abnormal = hard (firm), immobile (fixed), greater than 1cm

39
Q

s/s of hypothyroidism

A

-weight gain
-fatigue
-cold
-constipation
-large neck goiters
-dysthymia (depression)
-dry skin
-brittle nails
-low b/p, low HR

40
Q

s/s of hyperthyroidism

A

-weight loss
-heat intolerance
-tachy (high HR), high bp
-warm aka heat intolerance
-oily skin/hair
-anxious
-energetic
-hyper

41
Q

2 responsibilities of the lymph node system?

A
  1. immunity
  2. transport fluid back into circulation
42
Q

how to access the thyroid

A

feel for it! have pt swallow/drink water

43
Q

pre auricular lymph node

A

drains ear, possible ear infection if inflammed

44
Q

cervical lymph node (anterior cervical)

A

drains throat, may tonsil infection

45
Q

submental lymph node

A

near chin, so might have jaw or teeth infection

46
Q

what is peripheral vascular disease

A

-change in arterial blood flow d/t plaque

-resulting in coolness, paleness, lower HR, paresthesia (tingling), hypoesthesia (numb)

47
Q

this test tests for collateral circulation of radial & ulnar arteries, performed prior to drawing ABGs or insertion of an arterial line

A

Allen Test (fist test)

48
Q

pooling of blood in the veins often d/t inadequate venous return

A

venous stasis

(this can cause edema aka swelling, shiny skin, no hair growth, red/brown color from old blood)

49
Q

what is a pt at risk for if venous stasis occurs?

A

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)

50
Q

s/s of venous stasis?

A

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

51
Q

difference between Dysphagia vs Odynophagia

A

Odynophagia - painful swallowing

dysphagia - difficulty swallowing

52
Q

what is it called when pt has difficulty swallowing

A

dysphagia

53
Q

what is it called when pt has pain swallowing

A

Odynophagia

54
Q

What is s/s of a DVT?

A

unilateral pain, edema aka swelling, erythema aka red, heat… immediately call provider!

55
Q

detecting changes in blood flow (color & temp changes)

if less than 3 seconds, this Is good.
if greater, then there is impaired circulation

A

capillary refill

56
Q

6 Ps for arterial occlusion

A
  1. Pain
  2. pallor
  3. poikilothermia
  4. paresthesia
  5. pulselessness
  6. paralysis
57
Q

coolness of an extremity may indicate this

other s/s include: pain, paresthesia (tingly), pallor (pale)

A

arterial occlusion

58
Q

s/s of a PE resulting from a DVT

A

acute dyspnea (SOB), chest pain, tachycardia (high HR), diaphoresis (sweating), anxiety

59
Q

difference between DVT vs acute arterial occlusion

A

DVT- clot that forms in vein
erythema (red)

acute arterial occlusion- blockage in peripheral artery impacting flow to limbs
pallor (pale)

60
Q

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)

A

VTE (venous thromboembolism)

61
Q

a pt is having right abdominal pain that radiates to the right scapula, which organ is a concern?

A

gallbladder

62
Q

blockage in peripheral artery impacting flow to limbs, contains the 6 Ps

A

acute arterial occlusion

6 Ps:
1. Pain
2. pallor
3. poikilothermia
4. paresthesia
5. pulselessness
6. paralysis

63
Q

enlarged liver (hepatomegaly) can be due to this

A

Cirrhosis
(due to hepatitis or chronic alcoholism)

64
Q

70% chance of death if pt has this

A

PE (pulmonary embolism) aka blood clot travels from legs to the lungs

65
Q

if cap refill is slow, you might have this

A

cold fingers

so do further investigation! warm them, check temp & vitals

66
Q

how to palpate the abdomen

A

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)

67
Q

enlarged liver d/t cirrhosis

A

hepatomegaly

68
Q

enlarged spleen d/t EBV aka Epstein-Barr Virus (mono)

A

splenomegaly

69
Q

sign of aging when it comes to GI

A

decreased peristalsis (movement during digestive process) leading to constipation

70
Q

bowel loop (or loop of bowel) protrudes through weak muscles, most common weak muscle is abdominal muscle

A

hernia

71
Q

why do we test for ascites (extra fluid in abdomen)

A

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

72
Q

these drain from the area above it

A

lymph nodes

73
Q

how long do you have to listen in abdomen prior to stating no bowel sounds

A

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)

74
Q

where is the Dorsalis pedis pulse

A

top of foot lateral to extensor longus tendon

75
Q

pinpoint of cervical/spine

A

C7

76
Q

Need to assess respiratory first if this area is injured

A

C4 & above

77
Q

population of ppl w/ gallbladder disease

A

(4 Fs) : Female, Fat, over Forty, Fertile

78
Q

risk factors for colorectal cancer (non modifiable & modifiable)

A

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

79
Q

positive (+) Murphy sign means what?

A

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

80
Q

light vs deep palpation of abdomen

A

light: 1-2cm

deep: 3-4cm

81
Q

what should you hear when you percuss over the abdomen

A

dull - over bone, solid area aka organ, or fluid

tympany - normal areas

82
Q

what does pain/tenderness when whacking on the back of a pt (CVA test aka costovertebral angle) identify?

A

pyelonephritis (kidney infection) or nephrolithiasis (kidney stones)

83
Q

normal assessment for lower extremities

A

Skin intact, warm/pink, pedal pulse palpable 2+, no pitting

84
Q

what can lead to odynophagia (painful swallowing) or dysphagia (difficulty swallowing)

A

GERD, Parkinson’s disease, hiatal hernia, stroke pts

85
Q

largest blood vessel

A

aorta

86
Q

pitting vs non pitting edema?
what’s the scale?

A

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

87
Q

elderly are at risk of this due to lack of sweat glands

A

hyperthermia & hypothermia

88
Q

What is McBurney’s pt used to assess?

A

appendicitis

(palpate RLQ near umbilici & anterior ileac crest… if pain then positive for appendicitis)

89
Q

what are the 2 signs to test for appendicitis?

A

-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)

90
Q

define skin of the elderly

A

dry, no hair, shiny due to poor venous blood flow

91
Q

signs of arterial insufficiency

A

pale, cold, pulseless or thready pulse leg

92
Q

this might be a sign of an aortic aneurism (ruptured aorta)

A

Pain in the epigastric area that radiates to the scapula with SOB aka dyspnea , sharp and stabbing pain!

93
Q

arterial insufficiency s/s

A

pale, cold, pulseless leg

94
Q

venous insufficiency s/s

A

dark brown leg due to old blood, warm and pink leg

Health Assessment (3 decks)

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