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HAP FINAL - CK > Weeks 3 & 4: Physical Exam, Vitals, Pain, Skin/hair/nails, violence > Flashcards

Weeks 3 & 4: Physical Exam, Vitals, Pain, Skin/hair/nails, violence Flashcards

1
Q

what is the typical order of physical assessment (except if doing abdominal)

A

inspect (always first!)
palpation
percussion
auscultation

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2
Q

Indirect percussion technique is used to determine

A

what is happening in the underlying structures – evaluated by auscultating the sounds.

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3
Q

where do you expect to hear “resonant” sound

A

normal lung tissue (clear and hollow sound)

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4
Q

hyperresonant

A

in an abnormal adult lung (but a NORMAL child’s lung)

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5
Q

tympany

A

air-filled viscus (stomach, intestine)

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6
Q

dull

A

dense organ (liver, spleen)

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7
Q

flat

A

large muscles (thigh), bone, tumor

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8
Q

when does the general survey begin

A

with the first moment of encounter!

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9
Q

Hyper pituitary dwarfism

A

lack of growth hormones-disproportionate body parts

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10
Q

Gigantism

A

excessive growth hormones in body

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11
Q

Cushing’s disease

A

excess of cortisol

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12
Q

addison’s disease

A

too little cortisol

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13
Q

Marfan syndrome

A

genetic disorder affects body’s connective tissue

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14
Q

Syndactyly

A

the condition of having some or all of the fingers or toes wholly or partly united, either naturally (as in web-footed animals) or as a malformation

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15
Q

normal temperature ranges

A

“NORMAL”
oral temp is 35.8C-37.3 C (96.4F-99.1F)
Rectal temp is 0.5C (1.0F) HIGHER
Axillary temp is 0.5C (1.0F) LOWER

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16
Q

pulse

A

normal pulse of adult is 60-100 bpm (never use thumb!)

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17
Q

vital signs

A 
pulse/HR
BP
O2 sat
RR
temp
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18
Q

korotkoff sounds

A 
we listen for these when taking blood pressure. 
5 sounds (1st sounds we hear is the systolic. Last sound is diastolic)
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19
Q

OXYGEN SATURATION

A

should be >90%. BUT, if pt is diagnosed with COPD, we do NOT want their O2 to be >90%. So, if they are at 87% we do NOT give them O2.

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20
Q

what pain scale do we use with demented PTs

A

PAINAD

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21
Q

Neonate responses to pain

A

global, evidenced by increased heart rate, hypertension, pallor, sweating, and decreased oxygenation saturation.

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22
Q

What intervention is most important to prevent nosocomial infections?

A

hand hygiene!

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23
Q

The patient is complaining of abdominal pain. What technique is used to form an overall impression

A

light palpation

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24
Q

Tympany is a percussion sound commonly located in the

A

abdomen

Percussion sounds are hyperresonant (diseased lungs), resonant (normal lungs), tympanic (abdomen), dull (over organs), and flat (over bone).

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25
Q

Which organs or body areas does the nurse auscultate as part of the admitting assessment

A

Heart, lungs, and abdomen

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26
Q

the diaphragm of the stethescope is used for ____ sounds

A

high frequency sounds (e.g. bowel sounds)

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27
Q

the bell of the stethescope is used for _____ sounds

A

low-frequency sounds (carotid arteries, bruit)

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28
Q

When assessing the child, the nurse makes the following adaptation to the usual techniques:

A

A pediatric stethoscope is used for better contact

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29
Q

The general survey includes

A

overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.

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30
Q

The nurse assesses the pulse for

A

rate, rhythm, amplitude, and elasticity

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31
Q

What are the four characteristics of respirations?

A

Rate, rhythm, depth, and quality

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32
Q

Oral temperature measurement is contraindicated in which patients

A

In PTs who have altered mental status, those who are mouth breathers, those who have had recent oral intake or who have recently smoked, and those who have recently undergone oral surgery.

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33
Q

what is an auscultatory gap

A

the period of no Korotkoff sounds during auscultation of a BP. It is caused by stiffening of the arterioles and is COMMON in the elderly and in those with chronic disease.

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34
Q

When performing indirect percussion, the examiner

A

strikes the stationary finger at the distal interphalangeal joint

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35
Q

A common error in BP measurement includes:

A

waiting less than 30 seconds before repeating the reading on the same arm

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36
Q

pruritis

A

itching

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37
Q

moles

A

nevi

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38
Q

striae

A

stretchmarks

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39
Q

seborrheic keratoses

A

extremely common in older adults!

Dark brown pigmented lesions are waxy-appearing areas seen on the trunk of the body.

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40
Q

actinic keratosis

A

aka solar keratoses (scaly, crusty growths/lesions caused by damage from the sun’s UV rays

41
Q

jaundice

A

increased serum billirubin, carotenemia, uremia

darker people can be seen on hands and soles and feet

42
Q

cherry angiomas

A

small (1-5mm) and increase with age
normal
typically on trunk or back
monitor to prevent changes

43
Q

erythema

A

hyperemia (excess of blood in vessels), polycythemia, carbon monoxide poisoning, venous stasis (blood pooling

44
Q

cyanosis

A

central (very serious), peripheral

heart not pumping blood or oxygen not getting to where it is needed

45
Q

Pallor

A

anemia, shock, arterial insufficiency

albinism, vitiligo

46
Q

Plaque

A

Primary skin lesion

Papules that are LARGER than 1.0 cm. Elevated, firm and rough, flat top (eczema)
lpsoriasis

47
Q

Nodule

A

Primary skin lesion

Solid, elevated, hard or soft, larger than 1 cm.extends deeper into dermis than papule. e.g intradermal nevi

48
Q

Bulla

A

Primary skin lesion

vesicle greater than 1cm, thin-walled, ruptures easily (blister, impetigo)

49
Q

cyst

A

Primary skin lesion

Elevated, circumscribed, encapsulated lesion, in dermis, or subcutaneous, filled with liquid (sebaceous cyst, cystic acne)

50
Q

vesicles

A

Elevated cavity containing free fluid up to 1 cm. - BLISTER. Clear serum flows if ruptured. e.g. herpes simplex, herpes zoster contact dermatitis

51
Q

wheal

A

Primary skin lesion

Raised, erythematous, irregular shape e.g. mosquito bite, allergic reaction

52
Q

fissure

A

Secondary Skin Lesions

Linear Crack or break from the epidermis to the dermis (Athlete’s foot, crack on mouth corners)

53
Q

scale

A

Scale Secondary Skin Lesions

compact, desiccated flakes of skin, dry or greasy, silvery or white, from sheddingo f dead excess keratin cells; ex - scarlet fever or drug reactions (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin

54
Q

crust

A

Secondary Skin Lesions

-thickened, dried out exudate left when vesicles/pustules burst or dry up; color can be red-brown, honey or yellow, depending on fluid’s ingredients (blood, serum, pus); ex - impetigo (dry, honey colored), weeping exzematous dermatitis, scab after abrasion)

55
Q

Pustule

A

Primary skin lesion

elevated, superficial lesion, filled with purulent fluid (impetigo, acne, herpes simplex)

56
Q

erosion

A

Secondary Skin Lesions

  • scooped out but shallow depression; superficial; epidermis lost; moist but not bleeding; heals w/o scar because erosions does not extend into dermis (varicella, candidiasis, herpes simplex)
57
Q

ulcer

A

Secondary Skin Lesions

deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals; ex - stasis ulcer, pressure sore, chancre

58
Q

excoriation

A

Secondary Skin Lesions

self-inflicted abrasion; superficial; sometimes crusted; scatches from intense itching; ex: insect bites, scabies, dermatitis, varicella

59
Q

scar

A

Secondary Skin Lesions

after skin lesion is repaired, normal tissue is lost and replaced w/ connective tissue (collage); this is permanent fibrotic change; ex-healed area after surgery (healed wound or surgical incision)

60
Q

skin assessment in older adult

A

decreased sebaceous and sweat gland-dry skin

loss of elasticity, collagen and mass

subcutaneous fat migrates to abdomen

skin may be cooler with edema

gray and thinning hair

nails become thicker, brittle, hard and yellowish

61
Q

Self exam of skin should include

A

ABCDE

look for:
asymmetry
border irregularity
color variation
diameter>6mm
elevation or enlargement
62
Q

vitiligo

A

white patches on skin. Caused by loss of pigment in skin d/t destruction of pigment-forming cell (melanocytes)

63
Q

what is the skin like in a PT with hyperthyroidism

A

smooth, soft, velvety

64
Q

what is the skin like in a PT with hypothyroidism

A

rough, dry, flaky

65
Q

what is extremely thin and shiny skin indicative of?

A

arterial insufficiency

66
Q

scleroderma

A

a chronic hardening and contraction of the skin and connective tissue, either locally or throughout the body

67
Q

Assessment of lesions includes:

A 
	1. Color
	2. Elevation
	3. Pattern or shape
	4. Size (use cm ruler)
	5. Location and distribution
	6. Exudate (discharge)
68
Q

annular

A

ring shaped

69
Q

confluent

A

flowing together or merging

70
Q

discrete

A

lesions that are separate and discrete (e.g. molluscum)

71
Q

gyrate

A

lesions that are coiled or twisted

72
Q

grouped

A

lesions that appear in clusters (e.g. purpural lesion)

73
Q

linear

A

lesions that appear as a line (scratches)

74
Q

target

A

lesions with concentric circles of color (e.g. erythema multiforme)

75
Q

zosteriform

A

(herpes or cold sores) arranged in a linear manner along a nerve route

76
Q

polycyclic

A

lesions that are circular but united (e.g. psoriasis)

77
Q

macule

A

have same characteristics as patches but are LESS than 1 cm. Flat and circumscribed e.g. freckles, petechiae, measles, scarlet fever

78
Q

papule

A

something you can FEEL, solid, elevated, LESS than 1 cm diameter)
caused by thickening of the epidermis.
e.g. wart, elevated mole

79
Q

patch

A

non palpable! Macules that are larger than 1 cm. e.g. cafe au lait spot, measles, rash

80
Q

tumor

A

Larger than a few centimeters in diameter, firm or soft, deeper into dermis.

81
Q

utricaria

A

hives

82
Q

excoriation

A

self-inflicted abrasion; superficial; sometimes crusted; scatches from intense itching; ex: insect bites, scabies, dermatitis, varicella

83
Q

atrophic scar

A

resulting skin level is depressed with loss of tissue; thinning of epidermis; ex – striae (stretch marks)

84
Q

lichenification

A

secondary skin lesion

(secondary to eczema or pruritus) – exaggerated skin lines. prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)

85
Q

keloid

A

hypertrophic scar; resulting skin level is elevated by excess scar tissue which is invasive beyond site of original injury

86
Q

secondary skin lesion

A
  • debris on skin surface: crust; scale

- break in continuity of surface

87
Q

venous ulcers

A

happen due to venous insufficiency. Due to improper venous function, usually happen in the legs

88
Q

hirsutism

A

excessive hair

89
Q

melism

A

sharply demarcated blotchy, brown maculesusually in a symmetricdistribution over the cheeks and forehead and sometimes on the upper lip and neck.It is most often seen in women during pregnancy (melasma gravidarum or “mask of pregnancy”

90
Q

linea nigra

A

black verticle line on stomach during pregnancy

91
Q

varicella (chicken pox) is characterized by

A

single to multiple erythematous vesicles anywhere on the body. As the disease progresses, the vesicles progress into shallow ulcers covered with scabs.

92
Q

measles is characterized by

A

a rash of macules and papules

93
Q

satelitte lesions are

A

Single lesions in close proximity to a larger lesion

94
Q

when taking the health Hx, the PT complains of pruritus. WHat is a common cause of this symptom?

A

allergic response

95
Q

what term refers to a linear skin lesion that runs along a nerve route?

A

zosteriform

96
Q

a scooped out, shallow depression in the skin (loss of part of the epidermis) is called

A

erosion

97
Q

the nurse is assessing for clubbing of the fingernails and would expect to find:

A

an angle of the nail base of 180 degrees or greater with a nail base that feels spongy

98
Q

how does the nurse recognize jaundice in a dark-skinned pt?

A

inspect the palms and soles for yellowish-green color

HAP FINAL - CK (9 decks)

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