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Health Assessment > quiz 2; skin-musc > Flashcards

quiz 2; skin-musc Flashcards

1
Q

function of skin

A

protection
waterproof
adaptive

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2
Q

epidermis

A

out layer made up of basal cell layer and horny cell layer

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3
Q

dermis

A

ct and collagen

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4
Q

subcutaneous

A

adipose tissue that stores fat for energy and provides insulation for temperature contorl, aids in protection

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5
Q

velllus

A

fine

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6
Q

terminal

A

course

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7
Q

sweat gland

A

maintain temperature
located in dermis layer

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8
Q

Additional skin questions for infants

A

birthmarks, changes in skin color, diaper rash, burns/bruises, exposures to contagious skin conditions, habitual movements, steps for sun exposure

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9
Q

Additional questions for aging adults

A

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

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10
Q

Inspection of skin

A

color changes
erythema, jaundice, pallor, cyanosis

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11
Q

erythema

A

redness of the skin or mucous membranes
d/t IN BF; fever; inflammation
- intense redness

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12
Q

jaundice

A

yellow color of skin d/t excess amounts of bilirubin in blood
- check junction of hard/soft palate, sclera, palm

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13
Q

Pallor

A

lightness of skin/mucous membranes
-d/t DE BF, O2, DE #RBC, vasoconstriction
-tongue coloring, check lips, conjunctive, nail beds

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14
Q

Cyanosis

A

blush color
d/t lung issues and DE oxygenated blood, DE perfusion

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15
Q

Palpatation

A

temperature, moistrue, texture, thickness, edema

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16
Q

temperature

A

should be warm and equally bilateral

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17
Q

moisture

A

checks skin and mucous membranes, could lead to diaphoresis vs dehydration

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18
Q

texture

A

smooth and firm, even suface

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19
Q

thickness

A

uniformly thin over most of the body

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20
Q

edema

A

fluid accumulations in tissue; feet, ankles, legs, face, hands

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21
Q

edema grading

A

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

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22
Q

Mobility

A

ability to raise skin

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23
Q

turgor

A

ability for skin to return to position

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24
Q

Pressure ulcers scale

A

Braden scale

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25
Q

stage 1 pressure ulcer

A

intact skin with redness

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26
Q

stage 2

A

loss of dermis presenting as shallow open ulcer, red and pink

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27
Q

stage 3

A

full thickness tissue loss, sub Q fat visible

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28
Q

stage 4

A

no nerves, full thickness loss with exposed bone, tendone, muscleu

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29
Q

unstagable pressure ulcer

A

slough and eschar

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30
Q

deep tissue pressure injury

A

black

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31
Q

DEVICE for pressure ulcers

A

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

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32
Q

Circullar

A

annular

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33
Q

grouped together

A

confluent

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34
Q

in a line

A

linear

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35
Q

within a border

A

circumscribed

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36
Q

Infant skin

A

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

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37
Q

vernix caseoa

A

moist white substance on skin

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38
Q

lanugo

A

fine downy hair

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39
Q

milia

A

baby acne

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40
Q

Older adult skin consideration

A

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

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41
Q

Pregnancy

A

straie, line nirgia, chloasma, vascular spiders, edema, varicose veins

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42
Q

ABCDE of melanoma

A

Asymmetrical
Border irregularity
Color variation
Diameter grater than 6mm
Elevation

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43
Q

Head, face, and neck subjective data

A

headache, injury, dizziness

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44
Q

head, face, neck
objective data

A

Size: head circumferance, normocephalic, round, symmetric
Shape: assess by placing fingers in hair and palpate the scalp

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45
Q

Face

A

Inspection: expression, symmertry, involuntary movement, skin color changes, swelling
Palpitations: muscle tone, TMJ, cranial nerves

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46
Q

Neck

A

symmetry
ROM
Cranial nerve XI
Thyroid gland

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47
Q

Nose

A

Shape, size, color
Patency
Cranial Nerve 1
Nasal cavity

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48
Q

Sinus palpation

A

feel firm pressure without pain
frontal sinuses by pressing under the eyebrows
maxillary sinuses by pressing below the cheek bone

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49
Q

mouth

A

cranial nerve X/XII
color, moisture
tounge
plalate
uvula

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50
Q

throat

A

observe oval, rough surface tonsils
CN XII
tonisls normally seen healthy people

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51
Q

fontanels

A

opening in skull of an infant, brain and skull still need to grow, anterior and posterior
- head is bigger than first 6 months

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52
Q

lymph node assessment

A

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

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53
Q

Tonsil grading

A

1: visible
2: halfway between tonsillar pilalr and uvula
3: touching uvula
4: touching eachother

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54
Q

How do you assess Mental status

A

A, B, C, T

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55
Q

Appearance

A

posture
body movement
grooming
hygeine

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56
Q

behavoir

A

LOC
Mood and affect
Facial expression
Speech

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57
Q

LOC Behaviors

A

Alert
Lethargic
Obtunded
Stupor
Coma
Delirium

58
Q

Alert

A

awake/readily aroused; orient; fully aware of stimuli and response appropriatly

59
Q

Lethargic

A

no fully alert; drifts to sleep when not stimulated; can be aroused when name caleld in normal voice; slow/fuzzy thinking

60
Q

Obtunded

A

transition state between lethargy and stupor; sleep most of time; difficult to arouse; speech may be mumbled and incoherent

61
Q

Stupor

A

spontaneously uncoinscoius; response to pain or any stimuli

62
Q

coma

A

completely unconscoius; no response to pain or stimuli

63
Q

delirium

A

acute confusional state; cloud of consciousness; inattentive in coherent conversation
SUDDEN onset of mental health changes

64
Q

Cognition

A

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

65
Q

Thought process

A

Perception
Thought content
Screen for anxiety
Screen for depression

66
Q

Glasgow coma scale

A

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

67
Q

Cognitive assessment

A
  • Montreal cognitive assessment
  • Mini Cog
  • Measure cognitive ability
68
Q

Depression Screening

A
  • Minimal symptoms: 5-9
  • Minor Depression: 10-14
  • Major depression, moderatly severe: 15-19
  • Major depression, severe: 20+
69
Q

CN I

A

Olfactory, Sensory
- Not routinely tested
- can smell

70
Q

CN II

A

Optic, Sensory
PERRLA
-Pupils are equal, round, and reactive to light/accommodation
Snellen Chart: acuity
Confrontation: peripheral

71
Q

CN III

A

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

72
Q

CN IV

A

Tochlear, Motor
Down/inward eye movement

73
Q

V

A

Trigeminal, Mixed
Motor: palpate muscle of mastication, check as pt clenches teeth
Sensory: check stimulus on face with pt eyes closed

74
Q

CN VI

A

Abducens, Motor
-Lateral eye movment
Hischberg Test

75
Q

CN VII

A

Facial, Mixed
Motor: smile, frown, puff out cheeks, close eyes
Sensory: check taste

76
Q

CN VIII

A

Acoustic, sensory
normal conversation and whisper test, normal is 4/6 correct

77
Q

CN IX

A

Glossopharyngal, mixed
soft palate, tonsil, uvula, tonuge, taste, swallowing

78
Q

CN X

A

Vagus, Mixed
Motor: ah/yawn, midline move
Sensory: stimulation of pharyngeal wall, avoid gag reflex

79
Q

CN XI

A

spinal accessory
Motor
Sternomastiod and trapezius muscle
-shrug and turn chin

80
Q

CN XII

A

hypoglossal
motor
insepct tounge on midline
clear speech

81
Q

Motor assessment

A

size, strength, tone

82
Q

Size of muscle

A

inspect all muscle groups, compaire bilaterally, normal for age, symmetical

83
Q

Strength of muscles definition

A

test muscle groups of extremiteis, neck and trunk

84
Q

Muscle tone

A

normal degree if tension involuntary relaxed muscles; move extremities through a PROM; normal should be smooth and coordinated

85
Q

Sensory

A

Intactness of PNS, sensory tracts, higher cortical discrimination
-close eyes, make sure bilateral

86
Q

Anterioir spinothalmic tract sensory tests

A

pain: sharp/dull test
light: cotton ball test

87
Q

Posterioir dorsal column tract sensory tests

A

virbation: tuning fork stop and start
position: passive movements of extremiteis
Tactile discrimination

88
Q

tactile discrimination tests

A

sterognosis: place familar objects in pt hand and ask to identify
Graphesthesia: trace number on palm and ask pt to identify

89
Q

coordination tests

A

RAM, finger nose finger test, heel to shin test

90
Q

Balance tests

A

gait
romberg

91
Q

DTR

A

how intact deep tendon reflexes are

92
Q

Biceps reflex

A

contraction of biceps muscle and flexion of forearm

93
Q

Brachioadialis

A

flexion and supination of the forearm

94
Q

triceps

A

extension of forearm

95
Q

quadriceps

A

extension of lower leg

96
Q

achilles

A

foot plantar flexes against hand

97
Q

clonus

A

rapid and rhytmic contractions of the calf muscle and movement of foot

98
Q

babkinski

A

superfiscal reflex
normal -plantar flexion
positive- extension of great toe and fanning of the rest

99
Q

Documentation of reflexes

A

grading
0= no response
1+ diminished
2+ average/normal
3+ brisker than average
4+ hyperactive with clonus, indicative of disease

100
Q

Neuro recheck

A

pt who has neurologic deficis that require periodic assessments, focused assessment

101
Q

complete neuro exam

A

mental status
cranial nerves
motor system
sensory system
reflexes

102
Q

Order of Muscoloskeletal assessment

A

Inspection
Palpation
ROM
Muscle testing

103
Q

Inspection

A

Shape and size of muscle, bone, and joint
- evaulte use of extremity
- check for color, swelling, deofrmity

104
Q

Palpation of muscles

A
  1. Location
    temperature
    muscle strength
    boney articulation
    swelling/fluid
    crepitation (creaking)
    ROM (passive)
105
Q

ROM

A

movement of a joint from full extension to full flexion

106
Q

AROM

A

can pt do it on their own

107
Q

PROM

A

nurse performs ROM exersizes, while pt relaxes muscles, stop when you feel resistance

108
Q

Strength

A

pt flex = you hold
pt extend = push

109
Q

Grade 5

A

FROM against gravity, full resistance: 100% normal, normal assessment

110
Q

Grade 4

A

FROM against gravity; some resistance; 75% normal, good assement

111
Q

Grade 3

A

FROM gravity 50% normal, fair assessment

112
Q

Grade 2

A

FROM with gravity eliminated passive motion; 25% normal, poor assessment

113
Q

Grade 1

A

slight contraction; 10% normal, trace assessment

114
Q

Carparl Tunnel Syndrome

A

Phalen’s Test and Tinels sign
d/t neurlogic disorder with radial nerve (hand bakc to back)
r/t computer use

115
Q

Phalines

A

flex wrist for 60 seconds, postive with numbness

116
Q

Tinels

A

tapping over wrist, positive tingling with tingles

117
Q

Bone growth

A

rapid infancy, stead in childhood, rapid adolescence, completed by age 20

118
Q

Pregnancy muscle changes

A

IN hormal mobility of joints, lordosis, waddling gait

119
Q

Older adults MS changes

A

kyphosis, loss of height, loss of bone density, bony prominences, get up and go test, functional assessment ADLs.

120
Q

Kypohsis

A

common in older aduls, cervical deformity

121
Q

Lordosis

A

common in childhood and pregnancy
lombar and thoracic deformitiy

122
Q

Bowlegs

A

knees push apart

123
Q

Knock knees

A

knees push together

124
Q

Scoliosis

A

common in adolescents
foward bend test
functional is flexible
structural is fixed

125
Q

Macule

A

circular, nonconfined, less than 1 cm with round boundries

126
Q

Patch

A

non circular, irregular boundries, greater than 1 cm, skin color change

127
Q

papule

A

raised, greater than 1 cm

128
Q

pustule

A

raised, varies in size, filled with pus

129
Q

nodule

A

greater than 1 cm
hard and elevated

130
Q

crust

A

dried exudate on the skin

131
Q

scales

A

dried skin seperate from normal skin

132
Q

vesicles

A

filled with water
less than 1 cm

133
Q

bulla

A

greater than 1 cm, filled with water

134
Q

ecchymosis

A

large bruise

135
Q

petechia

A

tiny bruises

136
Q

fissure

A

cracked

137
Q

erosion

A

into the epidermis

138
Q

ulcer

A

skin break down into the dermis

139
Q

excoriation

A

linear, scratch

140
Q

abrasions

A

deep
irregular shaped, torn patch

141
Q

types of skin issues

A

macule
patch
papule
pustle
nodule
crust
scales
vsicles
pustule
bulla
ecchymosis
petchia
fissure
erosion
ulcer
exoriation
abraisions

Health Assessment (3 decks)

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