Test 2 Health Assessment

Front 1

Pallor Signs

Back 1

Light: Generalized pallor
Dark: Brown skin is yellow-brown; black skin is gray, dull; look @ conjunctivae, mucous membranes to tell.

Front 2

Cyanosis Signs

Back 2

LIght: dusky blue
Dark: dull, lifeless; only severe cyanosis is seen in skin; check oral mucosa, nail beds

Front 3

Erythema

Back 3

Light: Red, bright pink
Dark: purplish tinge, difficult to see; palpate for warmth, taut skin, hardening of deep tissues.

Front 4

Annular

Back 4

circular
begins in center and spreads to periphery

Ex. ringworm, tinea corporis, inea versicolor, pityriasis rosea

Front 5

Confluent

Back 5

lesions run together

Ex. hives

Front 6

Discrete

Back 6

distinct, individual lesions that remain separate
Ex. molluscum

Front 7

Grouped

Back 7

clusters of lesions

Ex vesicles of contact dermatitis

Front 8

Gyrate

Back 8

twisted, coiled spiral, snakelike

Front 9

Target

Back 9

resembles iris of eye
concentric rings of color in lesions

Ex. erythema multiforme

Front 10

Linear

Back 10

A scratch, streak, line, or stripe

Front 11

Polycyclic

Back 11

annular lesions grow together

ex. lichen planus, psoriasis

Front 12

Zosteriform

Back 12

linear arrangement along a nerve route

Ex. Herpes zoster

Front 13

Macule

Back 13

Color change
flat, and circumscribed of less than 1 cm (doesn't have to be round)

ex. freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.

Front 14

Papule

Back 14

can feel it with palpatation (solid, elevated, circumscribed less than 1 cm). caused by superficial thickening of epidermis

Ex mole, wart, molluscum

Front 15

patch

Back 15

macules that are larger than 1 cm

ex. mongolian spot, vitligo, cafe au lait, measles rash

Front 16

plaque

Back 16

coalesce to form surface elevation wider than 1 cm.
A plateau-like, disc-shaped lesion

ex. psoriasis, lichen planus

Front 17

nodule

Back 17

solid, elevated, hars or soft, larger than 1 cm.
may extend deeper into dermis than papule.

ex. fibroma, intradermal nevi

Front 18

wheal

Back 18

superficial, raised, transient, erythematous
slightly irregular shape due to edema (fluid held diffusely in tissues)

ex. mosquito bite, allergic rxn, dermographism

Front 19

tumor

Back 19

larger than a few centimeters in diameter, firm or soft, deeper in to dermis; benign or malignant

ex lipoma hemangioma

Front 20

urticaria (hives)

Back 20

wheals coalesce to form extensive reaction, intensely pruritic

Front 21

vesicles

Back 21

elevated cavity containing free fluid, up to 1 cm
"blister"
clear serum flows if wall is ruptured
ex: herpes simplex, chicken pox, shingles, contact dermatitis

Front 22

bulla

Back 22

larger than 1 cm in diameter
usually single chambered, superficial in epidermis
thin walled, so easily ruptures

ex. friction blister, burns, contact dermatitis

Front 23

cyst

Back 23

encapsulated fluid filled cavity in dermis or subcutaneous layer, tensely elevating skin

ex. sebaceous cyst

Front 24

pustule

Back 24

turbid fluid (pus) in the cavity. circumscribed and elevated.

ex. impetigo, acne

Front 25

crust

Back 25

thickened, dried-out exudate left when vesicle/pustule burst or dries up.

color can be red-brown, honey, yello.

Front 26

scale

Back 26

compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells.

Front 27

fissure

Back 27

linear crack with abrupt edges, extends in to dermis, dry or moist

Front 28

erosion

Back 28

scooped out but shallow depression. usually heals without scar, superficial, moist but no bleeding.

Front 29

ulcer

Back 29

deeper depression extending in to dermis, irregular shape, may bleed, leaves scar when heals.

Front 30

excoriation

Back 30

self inflicted abrasion, superficial, sometimes crusted, scratches from intense itching.

Front 31

scar

Back 31

after a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). permanent fibrotic change.

Front 32

atrophic scar

Back 32

resulting skin level depressed with loss of tissue. thinning of epidermis.

Front 33

lichenification

Back 33

prolonged intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss.

Front 34

keloid

Back 34

a hypertrophic scar. resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury. may increase long after healing occurs. looks smooth, rubery, "clawlike."

higher incidence among blacks.

Front 35

Peripheral cyanosis (exposure to cold, anxiety)

Back 35

Light: dusky nail beds
Dark: dull, lifeless; only severe cyanosis apparent in skin (check conjunctivae, oral mucosa, nail beds)

Front 36

erythema (hyperemia)

Back 36

Light: red, bright pink
Dark: purplish tinge, but difficult to see; palpate for warmth from inflammation, taut skin, and hardening of deep tissues.

Front 37

erythema (polycythemia)

Back 37

LIght: ruddy blue in face, oral mucosa, conjunctiva, hands and feet
Dark: well concealed by pigment--check for redness in lips

Front 38

erythema (carbon monoxide poisoning)

Back 38

Light: bright cherry red in face and upper torso
Dark: cherry red color in nail beds, lips, and oral mucosa

Front 39

erythema (venous stasis)

Back 39

Light: dusky rubor of dependent extremities; a prelude to necrosis with pressure sore
Dark: easily masked; use palpation for warmth or edema

Front 40

jaundice (increased serum bilirubin)

Back 40

LIght: yellow in sclera, hard palate, mucous membranes, then over skin
Dark: check sclera for yellow near limbus, but do not mistake normal yellowish fatty deposits in the periphery under eyelids for jaundice (check hard and soft palate)

Front 41

jaundice (carotenemia)

Back 41

Light: yellow-orange in forehead, palms and soles, nasolabial folds, but no yellowing in sclera or mucosa membranes
Dark: yellow-orange tinge in palms and soles

Front 42

jaundice (uremia)

Back 42

Light: orange-green or gray overlaying pallor of anemia; may have ecchymoses and purpura
Dark: easily masked, rely on lab findings

Front 43

brown-tan (addison's dz)

Back 43

LIght: bronzed appearance, an "eternal tan" around nipples, perineum, genitalia, and pressure points.
Dark:easily masked; rely on lab and clinical findings

Front 44

subjective data for skin assesment

Back 44

hx of skin dz, change in pigmentation, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion, medications, hair loss, change in nails, environmental or occupational haz, self care behaviors

Front 45

preauricular lymph nodes

Back 45

two in front of ear

Front 46

posterior auricular lymph nodes (mastoid)

Back 46

superficial to the mastoid process

Front 47

occipital lymph nodes

Back 47

at base of skull
(HIV--painless and nontender)

Front 48

jugulodigastric lymph nodes

Back 48

under the angle of the mandible

Front 49

superficial cervical lymph nodes

Back 49

overlying the sternomastoid muscle

Front 50

posterior cervical lymph nodes

Back 50

in the posterior triangle along the edge of the trapezius muscle

Front 51

supraclavicular lymph nodes

Back 51

(breast cancer)
just above and behind the clavicle, at the sternomastoid muscle.

Front 52

submandibular lymph nodes

Back 52

halfway between the angle and the tip of the mandible

Front 53

submental lymph nodes

Back 53

midline, behind the tip of the mandible

Front 54

deep cervical lymph nodes

Back 54

deep under the sternomastoid muscle

Front 55

lymph assessment subjective data

Back 55

headache, head injury, dizziness, neck pain or limitation of motion, lumps or swelling, history of head or neck surgery.

Front 56

normal adult thorax position

Back 56

thorax has elliptical shape with aneroposterior to transverse diameter of 1:2 or 5:7

Front 57

barrel chest

Back 57

A-to-T diameter is equal
ribs are horizontal instead of having normal downward slope. associated with normal aging, and also with emphysema and asthma.

Front 58

pectus excavatum of thorax

Back 58

sunken sternum
depression begins at second intercostal space, becoming depressed most at xiphoid. congenital. may cause embarrassment.

Front 59

pectus carinatum

Back 59

forward protrusion of sternum. ribs slope back at either side. (pigeon breast).

Front 60

scoliosis

Back 60

s shaped curvature of thorax and lumbar spine. unequal shoulder and scapular height and unequal hip levels. prevalent in adolescent girls. may reduce lung volume and person is at risk for impaired cardiopulmonary funct.

Front 61

kyphosis

Back 61

exaggerated posterior curvature of throacic spine (humpback). impaires cardiopulmonary function. neck muscles compensate to keep head at level of vision.

Front 62

normal adult respirations

Back 62

reate: 10-20
depth: 500-800 mL
pattern: even
depth: air moves in and out with resp.

Front 63

tachypnea

Back 63

rapid shallow breating.
rate 24 or greater.
normal resp. to fever, fear or exercise.

Front 64

hyperventilation

Back 64

rate and depth increase.
occurs with extreme exertion, fear, anxiety. blow off carbon dioxide causing decreased level in blood (alkalosis).

Front 65

bradypnea

Back 65

slow breathing. decreased but regular rate of less than 10 rpm.

Front 66

hypoventilation

Back 66

irregular shallow pattern

Front 67

chronic obstructive breathing

Back 67

normal inspiration prolonged expiration because of airway resistance.

Front 68

cheyne-strokes respiration

Back 68

resp. wax and wane in reg. pattern, increasing in rate and depth and then decreasing. periods last 30 to 45 seconds. heart failsure is common cause.

Front 69

biot's respiration

Back 69

similar to cheyne but pattern is irregular. three to four resp. followd by a period of apnea. lasts anywhere from 10 to 1 min. seen in brain abscess, heat stroke, meningitis, or head trauma.

Front 70

discontinuous sounds

Back 70

discrete crackling

Front 71

crackles--fine

Back 71

rales. high pitched, short crackling, popping heard on inspiration and not cleared by coughing.

rolling a strand of hair between fingers.

Front 72

crackles--coarse

Back 72

loud, low pitched, bubbling and gurgling sounds start in inspiration and may be present in expiration.

Front 73

atelectatic crackles

Back 73

fine crackles that don't last and aren't pathologic.

Front 74

pleural friction rub

Back 74

coarse, low pitched superficial sound. has grating quality like rubbing two pieces of leater together.

Front 75

continuous sounds

Back 75

connected, musical sounds



acute asthma or chronic emphysema

Front 76

wheeze

Back 76

high pitched, musical squeaking. predom. in expiration but may occur in both.
*bronchitis

Front 77

stridor

Back 77

high pitched crowing sound on inspiration.

*foreign inhalation, obstructed airway

Front 78

bronchophony

Back 78

"ninety-nine"
in norm transmission it's soft, muffled, and indistinct.
in abnorm you will hear clear words.

Front 79

egophony

Back 79

"ee-ee-ee"
normal you should hear "eeeeee" but over area of consolidation or compression you will hear "aaaaaa"

Front 80

whispered pectoriloquy

Back 80

"one-two-three" is whispered
norm is faint, muffled, inaudible sounds
with consolidation the whispered voice is clear and distinct, although it sounds somewhat faint as if person were whispering it into your steth.