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28 Cards in this Set

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K.T. (all terms relative to head to toe assessment)
Alopecia
Def:Absence or loss of hair, esp. of the head.
Etiology:may result from serious illness, drugs, endocrine disorders, certain forms of dermatitis, hereditary factors, radiation, or physiological changes as part of the aging process
K.T.(all terms relative to head to toe assessment)
Alopecia: Treatment
may include drugs such as minoxidil or finasteride, surgeries, such as hair transplantation; or prostheses (wigs) (Taber, p. 78).
K.T.(all terms relative to head to toe assessment)
Cephalocaudal
The head to toe approach begins the examination at the head, progresses to the neck, thorax, abdomen, and extremities, and ends at the toes (p.269).
K.T.(all terms relative to head to toe assessment)
Cephalocaudal... what does the nurse do prior to the actual physical exam?
records a general impression about the client’s overall appearance and health status, for example, age, body size, mental and nutritional status, speech and behavior. Then the nurse takes such measurements as vital signs, height, and weight (p.269)
K.T.(all terms relative to head to toe assessment)
Clubbing
a condition in which the angle between the nail and nail bed is 180 degrees or greater.
Possible cause: long-term lack of oxygen. (P.542)
K.T.(all terms relative to head to toe assessment)
Clubbing: "Tabers" possible causes of this are:
COPD, interstitial fibrosis of the lungs, cyanotic congenital heart disease, carcinoma of the lung, bacterial endocarditis
K.T.(all terms relative to head to toe assessment)
Cyanosis
(Bluish tinge) is most evident in the nail beds, lips and buccal mucosa. In dark-skinned clients, close inspection of the palpebral conjunctiva (the lining of the eyelids) and palms and soles may also show evidence of cyanosis (p.535)
Often related to heart/lung disease. Can occur due to cold temp.
K.T.(all terms relative to head to toe assessment)
Ecchymosis
A bruise,i.e.superficial bleeding under the skin or a mucous membrane (Tabers, 659).
K.T.(all terms relative to head to toe assessment)
Edema
The presence of excess of interstitial fluid. Area appears swollen, shiny, and tau; tends to blanch the skin color or, if accompanied by inflammation, may redden the skin.
K.T.(all terms relative to head to toe assessment)
Generalized Edema often indicates:
...Impaired venous circulation and in some cases reflects cardiac dysfunction or vein abnormalities. (p.535)
K.T.(all terms relative to head to toe assessment)
Erythema:
Redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection.
K.T.(all terms relative to head to toe assessment)
Glossitis
Inflammation of the tongue (p.562)
Glossitis that develops in hours or days, often associated with stomatitis. The tongue is painful, red, inflamed and swollen. It may appear smooth smooth or be covered with popular lesions. Fever may be present.
K.T.(all terms relative to head to toe assessment)
Glossitis: Etiology
It may be associated with diabetes mellitus, bacterial infections, candidal infections, adverse drug reactions, smoking, and trauma to the tongue.
Treatment: The underlying disorder must be treated.
K.T.(all terms relative to head to toe assessment)
Issues relative to severe Glossitis:
Surrounding structures may be swollen sufficiently to produce asphyxia. Tracheostomy may be necessary to maintain the airway.
K.T.(all terms relative to head to toe assessment)
Hyperhidrosis
Sweating greater than would be expected considering the temperature of the environment.
K.T. (all terms relative to head to toe assessment)
Hyperhidrosis: Etiology
...Stimulants, sepsis, hyperthyroidism, menopausal hot flashes, obesity, intense activation of the sympathetic nervous system, and other conditions.
K.T. (all terms relative to head to toe assessment)
Tx. for localized Hyperhidrosis:
...Application of 20% solution of aluminum chloride hexadydrate in absolute alcohol at night using occlusive dressings is beneficial. The dressed sites must be dried before application and the salt washed away in the morning (Tabers, p. 1033).
K.T. (all terms relative to head to toe assessment)
Jaundice
(A yellowish tinge) may first be evident in the sclera of the eyes and then in the mucous membranes and the skin.
(Do not confuse jaundice with normal pigmentation in the sclera of a dark-skinned client. If jaundice is suspected, confirm by inspecting the posterior part of the hard palate for a yellowish color tone. (p.535)
K.T. (all terms relative to head to toe assessment)
Pallor
Usually characterized by the absence of underlying red tones in the skin and may be most readily seen in the buccal mucosa. In brown-skinned clients, the skin may appear ashen gray. Pallor in all people is usually most evident in areas with least pigmentation such as the conjunctiva, oral mucous membranes, nail beds, palms of the hand, and soles of the feet (p.535).
K.T. (all terms relative to head to toe assessment)
Pallor ussually a result of...
...inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation.
K.T. (all terms relative to head to toe assessment)
Paronychia
An acute or chronic infection of the marginal structures about the nail. Symptoms: Redness, swelling and suppuration around the nail edge occur. Treatment: Therapy may involve moist heat application, oral antigiotics, or surgical drainage. (Tabers, p.1600).
K.T. (all terms relative to head to toe assessment)
Sordes
The accumulation of foul matter (food, microorganisms and epithelial elements) on the teeth and gums. (p. 562)
K.T. (all terms relative to head to toe assessment)
Sordes: pt. Care:
Frequent oral hygiene for mouth breathers, patients who cannot drink or are not permitted oral fluids, and debilitates patients.
Hydrogen peroxide mouthwash (one part hydrogen peroxide to three parts water) or glycerin applied with a soft brush or sponge-stick may be used to remove crusts. Either treatment should always be followed by rinsing with clear water.
K.T. (all terms relative to head to toe assessment)
Stomatitis
Inflammation of the mouth (including the lips, tongue, and mucous membranes).
K.T. (all terms relative to head to toe assessment)
Stomatitis:Etiology...
variety of conditions including viral infections, chemical irritation, radiation, therapy, mouth breathing, paralysis of nerves supplying the oral area, chemotherapy that damages or destroys the mucous membranes, adverse reactions to other medicines, or acute sun damage to the lips. Nasal catheters.
Symptoms/Tx.:(Tabers, p. 2081)
K.T. (all terms relative to head to toe assessment)
Vitiligo
Seen as patches of hypopigmented skin, is caused by the destruction of melanocytes in the area. (p.535)
K.T. (all terms relative to head to toe assessment)
Validate
“Double-checking” or verifying data to confirm that it is accurate and factual.
K.T. (all terms relative to head to toe assessment)
Validating helps to... (x5)
...Ensure that assessment information is complete.
...Ensure that objective and related subjective data agree.
...Obtain additional information that may have been overlooked.
...Differentiate between cues and inference.
...Avoid jumping to conclusions