Skin (Chapter 25)

Front 1

Ecchymosis

Back 1

A collection of blood in the subcutaneous tissues, causing purplish discoloration.

Front 2

Edema

Back 2

Swelling, with taut and shiny skin. Accumulation of fluid in the interstitial space. Usually observed around the eyes, fingers, ankles, and sacral space. Can also accumulate in or around body organs.May be the result of overhydration, heart failure, kidney failure, trauma, or peripheral vascular disease.

Front 3

Erythema

Back 3

redness of the skin, seen in the face and neck, associated with sunburn, inflammation, fever, truama, and allergic reactions.

Front 4

Jaundice

Back 4

A yellow color of the skin resulting from liver and gallbladder disease, some types of anemia, and hemolysis.

Front 5

Pallor

Back 5

Paleness of the skin, a result of an inadequate amount of circulating blood or hg, causing inadequate oxygenation of the body tissues.

Front 6

Petechiae

Back 6

Small hemorrhagic spots caused by capillary bleeding. If present, assess their location, color, and size.

Front 7

Turgor

Back 7

The fullness or elasticity of the skin and is usually assessed on the sternum or under the clavicle. Normal turgor can be picked up in a fold and then returns to its shape when released. When dehydrated, elasticity is decreased. Difficulty may indicate edema.

Front 8

Purpose of Health History

Back 8

To collect subjective and objective data, to determine overall level of physical , psychological, sociocultural, developmental and spiritual health.

Front 9

Comprehensive Assessment

Back 9

A health history and complete physical exam, when the patient first enters a healthcare setting. The information provides a baseline for comparing later assessment.

Front 10

On-going partial Assessment

Back 10

Conducted at regular intervals, at the beginning of each home health visit or each hospital shift, during the care of the patient. Concentrating on identifying health problems to monitor positive or negative changes and to evaluate the effectiveness of the interventions.

Front 11

Focused Assesment

Back 11

To assess a specific problem.

Front 12

Emergency Assessment

Back 12

Rapid focused assessment conducted to determine potentially fatal situations.

Front 13

Physical Assessment

Back 13

Systematic collection of objective information. Conducted in a head-to-toe sequence or a system sequence but can be adapted to meet the needs of the patient.

Front 14

Stethoscope

Back 14

to listen to sounds of the heart, lungs, abdomen, and cardiovascular system.

Front 15

Ophthalmoscope

Back 15

to visualize the interior of the eye. A body that contains the light source and a detachable head that contains lenses the magnify the internal eye structures.

Front 16

Otoscope

Back 16

To examine the external ear canal and the tympanic membrane.

Front 17

Snellen Chart

Back 17

A screening test for distant vision. 11-lines of different sized type. Ranging from 20/10 to 20/200

Front 18

Nasal Speculum

Back 18

Used to visualize the lower and middle turbinates of the nose.1/2in into each nostril.

Front 19

Vaginal Speculum

Back 19

Used to examine the vaginal canal and cervix. Speculum is inserted into the vagina and the blades open. Speculum must be warmed and lubricated before insertion.

Front 20

Tunning Fork

Back 20

A two pronged metal instrument used to test auditory function and vibratory perception.

Front 21

Percussion Hammer

Back 21

A reflex hammer with a rubber head used to test deep tendon reflexes. a rapid downward and backward wrist action. A quick firm tap.

Front 22

Percussion

Back 22

To strike one object against another to produce sound. Used to assess location, shape, size and density of tissues.

Front 23

Auscultation

Back 23

To assess pitch, high to low. loudness soft to loud. quality gurgling or swishing. duration short, medium, or long.

Front 24

Palpation

Back 24

touch, to assess temperature (dorsum back of hand and fingers)., turgor, texture/shape/fluid/size/consistency/pulstion (palmar front of hand and fingers). moisture, vibrations (with the palm of the hand).Masses are determined by palpation. Two hands are used for bimanual palpaltion (for breast tissue) and shape.

Front 25

Inspection

Back 25

process of performing deliberate, purposful observations in a systematic manner. Visual, auditory, and smell to gather data. may be combined with palapation.

Front 26

Integument Assessment

Back 26

skin, nails, hair, scalp. data regarding self care activities to maintain health, hygeine and nutrition.

Front 27

cyanosis

Back 27

bluish or grayish discoloration of the skin in response to inadequate oxygenation. A blue tinge in patients with white skin and as dullness in patients with dark skin.