exam 3 Flashcards
stage 1 pressure ulcer
intact skin, non blanchable redness over bony prominence
stage 2 pressure ulcer
partial thickness tissue of dermis presenting as a shallow open ulcer with reddish pink would bed
stage 3 pressure ulcer
full thickness tissue loss with visible sub q fat, no muscle or bone exposure
stage 4 pressure ulcer
full thickness loss with exposed muscle or bone
ABCDEs of skin lesions
asymmetry
border
color
diameter
evolution
signs and symptoms of dehydrated individual
decreased turgor
dry mouth, kips, eyes
dark urine
dizzy
sunket eyes and cheeks
confluent lesions
smaller lesions run together to form a larger lesion
what assessment findings indicate jaundice?
yellow skin tones, sclera, oral mucosa, palms, and soles
1+ edema
mild pitting, 2 mm depression
2+ edema
moderate pitting, 4 mm depression disappears in 10-15 seconds
3+ edema
moderately severe pitting, 6 mm depression may last more than a minute
4+ edema
severe pitting, 8 mm depression can last more than 2 minutes
skin functions
protection
fluid & electrolyte balance
sensation
excretion
vitamin D
repair
external view of internal system
temperatuer regulation
youth and appearance
how to interpret a Braden scale score
lower Braden score= higher risk
< 18 indicates risk status
otitis media symptoms
red, bulging eardrum and diminished or absent light reflex
how are the tonsils graded
1+ normal size or no tonsils
2+ tonsils a little enlarged
3+ tonsil touching uvula; tonsils beyond pillars
4+ tonsils expand to midline
how should pupils react to penlight?
pupils constrict to direct and indirect light
what does PERRLA stand for
pupils
equal
round
reactive to
light and
accommodation
how to place otoscope in an adult ear
up & back
how to place otoscope in a child ear
down & back
where to you assess a dark-skinned person for pallor
eye & mouth lining
weber test
strike the tuning fork on top of the head
normal weber test
sound heard equally in both ears
abnormal weber test
hear louder in one ear than the other
conductive hearing loss
sound lateralizes to defective ear; something impairing passage of vibrations
sensorineural hearing loss
sound lateralizes to the better ear; damage to inner ear
rinne test
tuning fork at opening of the ear canal and patient states how long they hear the sound. once they can not hear it anymore, move tuning fork to the mastoid bone
what does rinne test
air and bone conduction
normal rinne test
AC > BC
abnormal rinne test
BC > AC
OD
ocular dexter (right eye)
OS
ocular sinister (left eye)
glaucoma
crescent shaped shadow in the iris, blurred vision, severe eye & head pain, nausea or vomiting, sudden sight loss
normal snellen chart reading
20/20 in both eyes
a patient can see at 20 feet what people normally see at 20 feet
what type of vision loss is glaucoma
gradual peripheral vision loss
macular degeneration
slow, progressive loss of central vision “you let the blinds down halfway”
retinal detachment
sudden appearance of floaters, flashes of light in one or both eyes, blurred vision
what type of vision loss is retinal detachment
gradual reduced peripheral vision; emergency!!
cataracts
blurry/cloudy vision, cannot see well at night, halo around lights
hypothyroidism
decreased metabolism; sensitive to cold, weight gain, constipation, muscle aches and weakness, fatigue, hair loss
hyperthyroidism
increased metabolism; sensitive to hear, hyperactivity, difficulty sleeping, feeling tired all the time, unintentional weight loss, rapid heartbeat
hirsutism
excessive facial hair on females, characteristic of Cushing disease
macule
small, flat, non-palpable skin color change less than 1 cm; ex. freckles, flat moles, port wine stains
papule
elevated, palpable, solid mass with border less than 0.5; ex. elevated nevi, warts
vesicle
circumscribed elevated, palpable mass containing serous fluid less than 0.5 cm; ex. herpes simplex/zoster, varicella, poison ivy
strabismus
constant misalighment of the eye
nystagmus
an oscillating movement of the eye, may be associated with an inner ear disorder, multiple sclerosis, brain lesions, or narcotics use
dysphagia
difficulty swallowing
entropion
inverted lower eye lid
ectropion
everted lower eye lid
exophthalmos
protruding eyeballs and retracting eye lids
presbycusis
gradual loss of hearing due to age, especially high-pitched sounds
adenopathy
large or swollen lymph nodes
lymph nodes to know
preauricular
postauricular
occipital
submental
submandibular
tonsillar
posterior cervical chain
posterior cervical chain location
behind ear and dow both sides
how do you palpate the thyroid gland?
stand behind patient, make sure their chin is lowered, ask patient to swallow and with one hand press and feel the thyroid move with the other
what documentation is important regarding skin lesions?
COLDSPA
type, color, shape, pattern, location, size, configuration
confrontation test
tests visual fields; you are sitting across from pt and hold your fingers out and have pt tell you when they can see your fingers
who is the control in the confrontation test
nurse
cardinals field of gaze
make sure eye movement is clean and smooth
ptosis
dropping of the lid
what are the visual abnormalities associated with age
glaucoma
macular degeneration
cataracts
acute angle glaucoma
sudden onset eye pain
risk factors for oral cancer
smoking, alcohol, exposure to HDV, male gender, older than 55, poor oral hygiene
temporal artery
palpate; tenderness and inflammation can lead to blindness
purpose of the cochlea
helps with balance
romberg test
tests for equilibrium
tragus
inner ear
