quiz 2; skin-musc Flashcards
function of skin
protection
waterproof
adaptive
epidermis
out layer made up of basal cell layer and horny cell layer
dermis
ct and collagen
subcutaneous
adipose tissue that stores fat for energy and provides insulation for temperature contorl, aids in protection
velllus
fine
terminal
course
sweat gland
maintain temperature
located in dermis layer
Additional skin questions for infants
birthmarks, changes in skin color, diaper rash, burns/bruises, exposures to contagious skin conditions, habitual movements, steps for sun exposure
Additional questions for aging adults
any changes in past few years, delays in wound healing, skin pain, changes in feet/toenails, recent falls, peripheral vascular disease/DM, skin care routine
Inspection of skin
color changes
erythema, jaundice, pallor, cyanosis
erythema
redness of the skin or mucous membranes
d/t IN BF; fever; inflammation
- intense redness
jaundice
yellow color of skin d/t excess amounts of bilirubin in blood
- check junction of hard/soft palate, sclera, palm
Pallor
lightness of skin/mucous membranes
-d/t DE BF, O2, DE #RBC, vasoconstriction
-tongue coloring, check lips, conjunctive, nail beds
Cyanosis
blush color
d/t lung issues and DE oxygenated blood, DE perfusion
Palpatation
temperature, moistrue, texture, thickness, edema
temperature
should be warm and equally bilateral
moisture
checks skin and mucous membranes, could lead to diaphoresis vs dehydration
texture
smooth and firm, even suface
thickness
uniformly thin over most of the body
edema
fluid accumulations in tissue; feet, ankles, legs, face, hands
edema grading
1+; mild pitting w slight indentation, no visible swelling
2+; moderate pitting indentation, subsides rapidly
3+ deep pitting indentation, remains for shrot time, leg looks swollen
4+ very deep pitting, indentaiton last long time, leg looks swollen
Mobility
ability to raise skin
turgor
ability for skin to return to position
Pressure ulcers scale
Braden scale
stage 1 pressure ulcer
intact skin with redness
stage 2
loss of dermis presenting as shallow open ulcer, red and pink
stage 3
full thickness tissue loss, sub Q fat visible
stage 4
no nerves, full thickness loss with exposed bone, tendone, muscleu
unstagable pressure ulcer
slough and eschar
deep tissue pressure injury
black
DEVICE for pressure ulcers
Detect: be aware of devices for skin break down
Every pt, every shift
Visualize and palpate skin under devices
Intervene: rotate device sit or securement of device
-patches, relieve pressure with pillows, heels, elevated, boots,
Cushion: with foam dressing to high risk areas
Educate pt and staff
Circullar
annular
grouped together
confluent
in a line
linear
within a border
circumscribed
Infant skin
less resistant, sensitive to chemical/physical/microbial influences, prone to drying out, sensitive to UV, difficulty regulating body temperature, sweat gland less active, circualtion slow to adapt, test mobility and turgor on abdomen, jaundice
vernix caseoa
moist white substance on skin
lanugo
fine downy hair
milia
baby acne
Older adult skin consideration
epidermis thins, dermis is less elastic, sub q fat bony prominences are more sharp, decreased sweat glands, melanocytes decrease, nails have slower growth, slow wound healing
Pregnancy
straie, line nirgia, chloasma, vascular spiders, edema, varicose veins
ABCDE of melanoma
Asymmetrical
Border irregularity
Color variation
Diameter grater than 6mm
Elevation
Head, face, and neck subjective data
headache, injury, dizziness
head, face, neck
objective data
Size: head circumferance, normocephalic, round, symmetric
Shape: assess by placing fingers in hair and palpate the scalp
Face
Inspection: expression, symmertry, involuntary movement, skin color changes, swelling
Palpitations: muscle tone, TMJ, cranial nerves
Neck
symmetry
ROM
Cranial nerve XI
Thyroid gland
Nose
Shape, size, color
Patency
Cranial Nerve 1
Nasal cavity
Sinus palpation
feel firm pressure without pain
frontal sinuses by pressing under the eyebrows
maxillary sinuses by pressing below the cheek bone
mouth
cranial nerve X/XII
color, moisture
tounge
plalate
uvula
throat
observe oval, rough surface tonsils
CN XII
tonisls normally seen healthy people
fontanels
opening in skull of an infant, brain and skull still need to grow, anterior and posterior
- head is bigger than first 6 months
lymph node assessment
comapre bilaterally and document
-normally feels moveable, discrete, soft, nontender
-adults are nonpalpable
acute infection: enlarged, bilaterally, tender, warm, mobile, soft to firm, pain
malignancy: hard, less than 3cm, matted, unilateral, non tender, fixed, rubbery
Tonsil grading
1: visible
2: halfway between tonsillar pilalr and uvula
3: touching uvula
4: touching eachother
How do you assess Mental status
A, B, C, T
Appearance
posture
body movement
grooming
hygeine
behavoir
LOC
Mood and affect
Facial expression
Speech
LOC Behaviors
Alert
Lethargic
Obtunded
Stupor
Coma
Delirium
Alert
awake/readily aroused; orient; fully aware of stimuli and response appropriatly
Lethargic
no fully alert; drifts to sleep when not stimulated; can be aroused when name caleld in normal voice; slow/fuzzy thinking
Obtunded
transition state between lethargy and stupor; sleep most of time; difficult to arouse; speech may be mumbled and incoherent
Stupor
spontaneously uncoinscoius; response to pain or any stimuli
coma
completely unconscoius; no response to pain or stimuli
delirium
acute confusional state; cloud of consciousness; inattentive in coherent conversation
SUDDEN onset of mental health changes
Cognition
Attention span: 8-10 seconds
Recent memory: 24 hours prior to assignment
Remote memory: birthdate, wedding date
Orientation: Person, place, time, reason
new learning: 3 new things, do they remember at the end of the assessment
Thought process
Perception
Thought content
Screen for anxiety
Screen for depression
Glasgow coma scale
severity of acute brain injury d/t trauma or medical reasons
- Mild: 13-15
- Moderate: 9-12
- Severe: 3-8
Worse as it gets lower
Cognitive assessment
- Montreal cognitive assessment
- Mini Cog
- Measure cognitive ability
Depression Screening
- Minimal symptoms: 5-9
- Minor Depression: 10-14
- Major depression, moderatly severe: 15-19
- Major depression, severe: 20+
CN I
Olfactory, Sensory
- Not routinely tested
- can smell
CN II
Optic, Sensory
PERRLA
-Pupils are equal, round, and reactive to light/accommodation
Snellen Chart: acuity
Confrontation: peripheral
CN III
Oculomotor, Mixed
-Cranial Nerve Action
- Eye Muscle Movements
Size of pupil
Accomodation
Opening eyelids
- Pt can follow movement wit finger in 6 positions (cat whiskers)
- Pt can parrell track
CN IV
Tochlear, Motor
Down/inward eye movement
V
Trigeminal, Mixed
Motor: palpate muscle of mastication, check as pt clenches teeth
Sensory: check stimulus on face with pt eyes closed
CN VI
Abducens, Motor
-Lateral eye movment
Hischberg Test
CN VII
Facial, Mixed
Motor: smile, frown, puff out cheeks, close eyes
Sensory: check taste
CN VIII
Acoustic, sensory
normal conversation and whisper test, normal is 4/6 correct
CN IX
Glossopharyngal, mixed
soft palate, tonsil, uvula, tonuge, taste, swallowing
CN X
Vagus, Mixed
Motor: ah/yawn, midline move
Sensory: stimulation of pharyngeal wall, avoid gag reflex
CN XI
spinal accessory
Motor
Sternomastiod and trapezius muscle
-shrug and turn chin
CN XII
hypoglossal
motor
insepct tounge on midline
clear speech
Motor assessment
size, strength, tone
Size of muscle
inspect all muscle groups, compaire bilaterally, normal for age, symmetical
Strength of muscles definition
test muscle groups of extremiteis, neck and trunk
Muscle tone
normal degree if tension involuntary relaxed muscles; move extremities through a PROM; normal should be smooth and coordinated
Sensory
Intactness of PNS, sensory tracts, higher cortical discrimination
-close eyes, make sure bilateral
Anterioir spinothalmic tract sensory tests
pain: sharp/dull test
light: cotton ball test
Posterioir dorsal column tract sensory tests
virbation: tuning fork stop and start
position: passive movements of extremiteis
Tactile discrimination
tactile discrimination tests
sterognosis: place familar objects in pt hand and ask to identify
Graphesthesia: trace number on palm and ask pt to identify
coordination tests
RAM, finger nose finger test, heel to shin test
Balance tests
gait
romberg
DTR
how intact deep tendon reflexes are
Biceps reflex
contraction of biceps muscle and flexion of forearm
Brachioadialis
flexion and supination of the forearm
triceps
extension of forearm
quadriceps
extension of lower leg
achilles
foot plantar flexes against hand
clonus
rapid and rhytmic contractions of the calf muscle and movement of foot
babkinski
superfiscal reflex
normal -plantar flexion
positive- extension of great toe and fanning of the rest
Documentation of reflexes
grading
0= no response
1+ diminished
2+ average/normal
3+ brisker than average
4+ hyperactive with clonus, indicative of disease
Neuro recheck
pt who has neurologic deficis that require periodic assessments, focused assessment
complete neuro exam
mental status
cranial nerves
motor system
sensory system
reflexes
Order of Muscoloskeletal assessment
Inspection
Palpation
ROM
Muscle testing
Inspection
Shape and size of muscle, bone, and joint
- evaulte use of extremity
- check for color, swelling, deofrmity
Palpation of muscles
- Location
temperature
muscle strength
boney articulation
swelling/fluid
crepitation (creaking)
ROM (passive)
ROM
movement of a joint from full extension to full flexion
AROM
can pt do it on their own
PROM
nurse performs ROM exersizes, while pt relaxes muscles, stop when you feel resistance
Strength
pt flex = you hold
pt extend = push
Grade 5
FROM against gravity, full resistance: 100% normal, normal assessment
Grade 4
FROM against gravity; some resistance; 75% normal, good assement
Grade 3
FROM gravity 50% normal, fair assessment
Grade 2
FROM with gravity eliminated passive motion; 25% normal, poor assessment
Grade 1
slight contraction; 10% normal, trace assessment
Carparl Tunnel Syndrome
Phalen’s Test and Tinels sign
d/t neurlogic disorder with radial nerve (hand bakc to back)
r/t computer use
Phalines
flex wrist for 60 seconds, postive with numbness
Tinels
tapping over wrist, positive tingling with tingles
Bone growth
rapid infancy, stead in childhood, rapid adolescence, completed by age 20
Pregnancy muscle changes
IN hormal mobility of joints, lordosis, waddling gait
Older adults MS changes
kyphosis, loss of height, loss of bone density, bony prominences, get up and go test, functional assessment ADLs.
Kypohsis
common in older aduls, cervical deformity
Lordosis
common in childhood and pregnancy
lombar and thoracic deformitiy
Bowlegs
knees push apart
Knock knees
knees push together
Scoliosis
common in adolescents
foward bend test
functional is flexible
structural is fixed
Macule
circular, nonconfined, less than 1 cm with round boundries
Patch
non circular, irregular boundries, greater than 1 cm, skin color change
papule
raised, greater than 1 cm
pustule
raised, varies in size, filled with pus
nodule
greater than 1 cm
hard and elevated
crust
dried exudate on the skin
scales
dried skin seperate from normal skin
vesicles
filled with water
less than 1 cm
bulla
greater than 1 cm, filled with water
ecchymosis
large bruise
petechia
tiny bruises
fissure
cracked
erosion
into the epidermis
ulcer
skin break down into the dermis
excoriation
linear, scratch
abrasions
deep
irregular shaped, torn patch
types of skin issues
macule
patch
papule
pustle
nodule
crust
scales
vsicles
pustule
bulla
ecchymosis
petchia
fissure
erosion
ulcer
exoriation
abraisions
