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185 Cards in this Set
- Front
- Back
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What are the three layers of skin? (ranging from outermost to inner most)
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Epidermis, dermis, subcutaneous
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Purpura
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red-purple, non-blanchable discoloration greater than 1cm
cause: intravascular defects, infection |
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Petechiae
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red-purple nonblanchable discoloration less than 1cm
cause: intravascular defects, infection |
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Ecchymoses
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red purple nonblanchable variable size
cause: vascular wall destruction, trauma, vasculitis |
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Spider Angioma
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red central body radiating spiderlike legs that blanch with pressure
cause: liver disease, vitamin B deficiency, idiopathic |
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Venous Star
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bluish spider, linear or irregularly shaped, does not blanch with pressure
cause: increased pressure in superficial veins |
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Telangieclasia
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fine irregular red line
cause: dilation of capillaries |
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Capillary hermangioma
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red irregular macular patches
cause: dilation of dermal capillaries |
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Nonpalpable
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macule: localized changes in skin color less than 1 cm in diameter
ex. freckle |
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Macule
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a flat, circumscribed area that is a change in the color of skin; less than 1 cm in diameter
ex. freckles, flat moles, petechiae, measles, scarlet fever |
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patch
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flat, nonpalpable,localized changes in skin color greater than 1 cm in diameter
ex. vitiligo, stage 1 of pressure ulcer |
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papule
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solid, elevated lesion less than 1 cm in diameter
ex. warts, elevated nevi |
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plaque
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solid, elevated lesion greater than 1 cm in diameter
ex. psoriasis |
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nodules
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solid, elevated, extend deeper than papules into the dermis or subcutaneous tissues, 1-2cm
ex. lipoma, erythema nodosum, cyst |
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tumor
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elevated and solid lesion, may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter
ex. neoplasms, benign tumor, lipoma, hemangioma |
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wheal
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localized edema in the epidermis causing irregular elevation that may be pale or red
ex. insect bite or hive |
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vesicle
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accumulation of fluid between the upper layers of the skin; elevated mass containing serous fluid; less than 1 cm
ex. herpes simplex, herpes zoster, chickenpox |
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bullae
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same as vesicle only greater than 1 cm
ex. contact dermatitis, large second degree burns, bulbous impetigo, pemphigus |
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pustule
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vesicle or bullae that become filled with pus, usually describes as less than 0.5cm
ex. acne, impetigo, furuncles, carbuncles, folliculitis |
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cyst
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encapsulated fluid filled or semi solid mass in the subcutaneous tissue or dermis
ex. sebaceous cyst, epidemoid cyst |
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scales
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flaking of the skins surface
ex. dandruff, psoriasis, xerosis |
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lichenification
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layers of skin become thickened and rough as result of rubbing over a prolonged period of time
ex. chronic contact dermatitis |
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scar
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fibrous tissue that replaces dermal tissue after injury
ex. surgical incision |
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keloid
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irregular shaped, elevated, progressively, enlarging scar, grows beyond the boundaries of the wound, caused by excessive collagen formation during healing.
ex. burn scar |
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excoriation
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loss of the epidermis; linear hollowed out crusted area
ex. abrasion or scratch, scabies |
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fissure
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linear crack or break from the epidermis to the dermis; may be moist or dry
ex. athletes foot |
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erosion
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loss of part of the epidermis; depressed, moist, glistening, follows rupture of a vesicle or bulla
ex. varicella, variola after rupture |
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ulcer
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loss of epidermis and dermis; concave, varies in size
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crust
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dried serum, blood, pus on the surface of the skin
ex. impetigo |
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atrophy
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thinning of skin surface and loss of skin markings; skin translucent and paper like
ex. striae, aged skin |
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discrete
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individual, seperate, and distinct
ex. insect bites |
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grouped
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lesions are clustered
ex. herpes simplex |
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confluent
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lesions merge and run together
ex. childhood exanthema |
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linear
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lesion that form a line
ex. poison ivy |
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annular
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lesions arranged in a circular pattern
ex. ringworm |
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polycyclic
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lesions arranged in concentric circles
ex. eruptions from drug reactions |
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generalized
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scattered over the body
ex. measles |
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zosteriform
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linear arrangement along a nerve root
ex. herpes zoster |
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Correct nail angles
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160 degrees or less
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clubbing of nail
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more than 160 degrees
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Optimal nutrition
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nutrients are taken in to meet daily bodily needs and enough additional to support the body in times of metabolic stress
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Undernutrition
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nutrient intake is inadequate to meet bodily needs or nutritional reserves are depleated
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Overnutrition
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excess intake of nutrients, more than body needs. especially calories, sodium, fat
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% of Obesity
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children-14%
adolescents- 12% adults-33% |
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Birth Weight of Infants
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double birth weight at four months, triple at 1 yr.
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Aging Adult
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prone to undernutrition
contributors: poor physical/mental health, alcoholism, functional ability, poverty |
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Decrease in calories needs at age 51
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200 calories a day
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Decrease in calorie needs at age 75
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500 calories a day
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Nutritional Information to collect
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eating habits, wt. and wt. history, changes in appetite, taste, smell, recent surgery, trauma, chronic illness, vomiting, diarrhea, constipation, allergies, medications, self care behaviors, illegal drug use, exercise patters, family history
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Order of Examination
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inspection, palpation, percussion, auscultation
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Inspection
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process of observation, gait and stance, eye contact, demeanor, difficulty getting undresses, verbal statements, body language
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Palpation
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involves the use of hands, fingers to gain information. Look for position, texture, size, consistency, masses, fluid, crepitus.
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Ulnar surface of hand
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distinguishes vibration
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Dorsal surface of hand
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best for comparing temperature of body parts
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Light palpation
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1 cm deep
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Deep palpation
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4 cm deep
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Percussion
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striking one against another
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Tympany
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loudest percussion sound
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Other percussion sounds include
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hyperresonance, resonance, dullness, flatness
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Auscultation
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listening
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Diaphragm of stethoscope
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high pitched sounds
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Bell of stethoscope
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low pitched sounds
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Characteristics of sound
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intensity, pitch, duration, quality
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Cultural Competence
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cultural awareness, knowledge, skill, encounter
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Ethnocentrism
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own way of life, values, belief is most desirable. May view others with superiority
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Cultural assessment
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process professional interactions, etiquette, perception of space/distance, gender
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Cultural characteristics
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learned at birth, socialization process and language, related to environmental and technical factors and resources
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Universal Phenomenon
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no two cultures are alike, yet may be similar. ALL PEOPLE ARE BORN, LIVE and DIE within cultural context
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Subculture
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large groups of people within a culture
factors: ethnicity, religion, health related characteristics, gender, sexual preference |
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Cultural Values
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desirable or undesirable state of affairs
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Cultural Norms
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rules by which human behavior is governed,many times is not specifically articulated.
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Dominant Value Orientation
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shared because of early life experiences
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Destiny
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have little choice over genetic
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Harmony
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people exist with nature
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Mastery
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are to overcome the environment and natural forces
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Purpose of Existence: Being
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spontaneous expression of impulses, integral to existence
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Purpose of Existence: Being in becoming
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detachment, inner control, mediation desire to realize the self
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Purpose of Existence: doing
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active striving and accomplishment, externally applied standards
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Purpose of Existence: Lineal
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ordered succession continuity, may seek help from family and allow others to make decisions
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Purpose of Existence: collateral
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group goals: family honor is most important than personal goal.
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Nuclear Family
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husband, wife, children
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Religion/Spirituality
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concerned with the mysteries of life
ex. life vs. death, pain and suffering |
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Spirituality
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an effort to find meaning
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Religion
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organized system of beliefs concerning, cause, nature, purpose of the universe, especially belief in or the worship of god or gods
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Assessment of Spirituality
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patient satisfaction with life, future plans, purpose of life, harmony between self and life, religious activities, degree of involvement with religion
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Nurses assessment of self spirituality
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helps to gain and maintain the necessary spirituality to help patients face own crisis
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Seven Developmental Stages of Faith
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primal- infancy
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Intuitive Faith
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projective faith, early childhood imagination, perception, and feelings involves positive and negative powers
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Mythic/ Liberal Faith
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development of logical thinking, understand world order and meaning of life
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Synthetic
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conventional faith-adolescent and beyond, personal, unreflective
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Individualistic
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reflective stage, young adulthood, critical reflection on values and beliefs, understanding self and social systems, choices made about ideology, and life style
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Conjunctive Faith
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mid life and beyond, realized multiple interpretations of reality, reinterpretation of life and appreciation of symbols
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Universalizing Faith
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midlife and beyond, oneness with the power of being, visionary, devotes self to overcoming oppression and division
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Functions of the Skin
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protective covering for the body, structure and physiologic processes, protects against microbial and foreign substance invasion, retards fluid loss, regulates body temp., sensory perception, produces Vit D, excretes sweat, urea, lactic acid, express emotions
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Epidermis
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outermost portion of the skin- avascular.
2 major layers: stratum corneum, cellular stratum, basement membrane. |
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Statum Corneum
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protects body
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Cellular Stratum
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keratin cells are synthesized
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Basement membrane
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connects cellular stratum to dermis for nutrition
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Dermis
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separates epidermis from subcutaneous tissue. vascular and nourishes epidermal cells.
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Purpose of elastin, collage, reticulin fibers
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provide stability and resilence
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Sensory fibers
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complex network for pain, touch, temperature
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Autonomic motor nerves
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innervate blood vessels, glands, arrectres pilorum muscles
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Hypodermis
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connects dermis to underlying organs, composed of loose connective tissue with fatty cells
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Adipose Tissue
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provides insulation, shock absorption and caloric reserves
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Eccrine sweat glands
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skin surface, regulate body temperature
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Apocrine sweat glands
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found only in axillae, nipples, areola, anogenital area, eyelids, external ears
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Sebaceous glands
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secrete sebum, lipid rich, keeps skin and hair from drying out
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Sex hormones
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regulated the secretory activity
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Papilla
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supplies nourishment
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Melanocytes
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provide color
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Vellus Hair
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short, soft, non pigmented
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Terminal Hair
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longer, thicker, pigmented
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Stages of Hair growth
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anagen-growth
catagen-atrophy telogen-rest |
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Eponychium
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cuticle layer of skin covering nail root
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Paronychium
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soft tissue surround nail border
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Inspection of skin
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color, uniform appearance, thickness, symmetry, hygiene, lesions
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Palpation of Skin
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moisture, temperature, texture, turgor, mobility
lesions for depression, elevation |
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Turgor and Mobility of Skin
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Pinch at clavicle
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Vestibule
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space between the buccal mucosa ad the outer surface of the teeth and gums
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Uvula
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hangs from posterior margin on soft palate
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How is the tongue anchored to the floor of the mouth?
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frenulum
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Gingiva
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fibrous tissue covered by mucous membrane attached directly to alveolar surface
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Inspection and Palpation of Mouth
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look for horizontal and vertical symmetry, movement of CN nerve 7, edema, lesions, look at border of lips and the rest of facial skin
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Inspection of teeth
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close mouth and ask to clench teeth, color, condition, number
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Inspection of Gingiva
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color-pink to coral, tight margin at tooth, sharp papillae
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Buccal Mucosa
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pale pink, smooth clear saliva, occlusion line
landmark: parotid duct |
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Hard and Soft pallate
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Hard- pale immovable with transverse rugae
Soft-pink, small red dots on surface, movable, symmetric with elevation CN 9 and 10 |
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Oropharynx
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landmarks: anterior and posterior pillars, symmetrical, uvula midline, tonsils
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Function of nose and sinuses
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identification of odors, passageway for inspired and expired air, humidification, warmth of inspired air, filtration
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Two bones that form the nasal bridge
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frontal and maxillary bones
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Kiesselback's Plexus
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convergence of small fragile arteries and veins located superficially on anterior superior portion of septum
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Cribiform Plate
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houses sensory endings of olfactory nerve, lies on roof of nose
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Function of Inferior medial and superior turbinates
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increase surface area of nose to warm, humidify, filter air
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How is the meatus named?
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meatus below is named for turbinate above
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Palpation of nose
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stability of nasal bridge, patency of nares, nasal mucosa,
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Bluish gray, pale pink swollen vestibule or turbinates
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due to allergies
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What is the neck composed of?
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muscles, ligaments, cervical vertebrae
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Landmarks of the neck
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anterior, posterior triangles, mid clavicular notch
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Alimentary tract
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tube approx. 27 feet long. extends from mouth to anus
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Function of alimentary tract
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ingest and digest food, absorb nutrients, electrolytes, and water, execrete wast products
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Peristalis
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moves the products of digestion along, under autonomic control
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Esophagus
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10 inches long, collapsible, connects pharynx to stomach
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Stomach
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flask shaped, lies transversely in upper abdominal cavity, below the diaphragm
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Three sections of abdomin
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fundus-above and left of cardiac orifice
body-mid 2/3 pylorus-most distal portion narrows and terminates in pyloric orifice |
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Small intestine
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21 feet long
duodenum-12 inches long forms "C" around head of pancreas jejunum-8ft long, becomes larger and thicker ileum-remaining 12 ft. |
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Function of ileocecal valve
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prevents back flow of fecal material
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Where does digestion take place?
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small intestine
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Large intestine
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4-5 ft. long, water absorption, putrefication of fead bacteria, undigested food residue, cellular debris, unabsorped amino acids
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Liver
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upper right quadrant, below diaphragm, heaviest organ in body, 3 lbs. in adult, highly vascularized
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Function of Liver
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metabolizing carbs, fats, proteins. stores vitamins, iron, detoxifies, produces antibodies, proteins
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Gallbladder
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sac like pear shaped organ about 4 inches long.
concentrates and stores bile from the liver. |
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Pancreas
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behind and beneath stomach, enzymes break down protein, fats and carbs
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Spleen
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Upper left quadrant above kidney
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Kidneys
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rt. kidney is slightly lower than left, regulates total body volume of fluid, produces renin
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Muscles of the abdomin
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anterior- recti abdomini
laterally-external and internal obliques linea alba-line done center of abdomin |
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Vasculature of abdomin
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at umbillicus the aorta branches into two common iliac arteries: splenic and renal
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Bluish periumbillical region
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intra-abdominal bleeding
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Bowel sounds
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5-34 per minute, if absent listen for five minutes
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Iliopsoas Test
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Hand on lower rt. thigh. ask pt. to raise and flex thigh, give resistance.
positive if pain in lower rt. quadrant |
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Obturator Test
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suspected ruptured appendix or pelvic abcess.
pain in hypogastric area is positive |
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Anterior portion of lungs
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sternum, manubrium, xyphoid process, coastal cartilage
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Lateral portion of lungs
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12 pairs of ribs
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Posterior Portion of lungs
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12 throacic vertebrae
upper 7-attached to sternum next 3-attached to eachother last 2- not attached |
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Primary muscles of respiration
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diaphragm and intercostals
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Which direction does the diaphragm move during inspiration?
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downward
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Three major spaces of interior chest
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rt. lt. pleural cavity, mediastinum
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How many lobes are in each lung?
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right-3
left-2 |
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Trachea
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10-11 cm long, 2 cm diameter, lies anterior to esophogus and posterior to isthmus of thyroid
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Bronchial arteries
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branch from ant. thoracic aorta to intercostal arteries, supplies blood to lung parenchyma and stroma
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Stroma
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supporting tissue
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Parenchyma
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functional tissue
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Landmarks of the lungs
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nipples, manubriosternal junction, suprasternal notch, costal angle, clavicles
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Cheyne-Stokes
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intervals of apnea followed by crescendo/decrescendo. END OF LIFE BREATHING
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Kussmaul
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rapid, deep breathing
metabolic acidosis |
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Pleural friction rub
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palpable coarse grating vibration on inspiration
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Crepitus
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air in subcutaneous spaces
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Tactile fremitus
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palpable vibration of chest wall. speak 99
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Decreased of absent femitus
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excess air in lungs, pleural thickening, massive pulmonary edema, bronchial obstruction
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Increased fremitus
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fluids or solid mass, lung consolidation, heavy non obstructive bronchial secretions
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Diaphragmatic excursion
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deeply inhale and mark fully exhale and mark. 3-5cms
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Vesicular lung sounds
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heard over lung fields. low pitch, soft, short exp.
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Bronchovesicular
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main bronchus, over rt. upper post lung field
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Bronchial
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trachea, high pitch, loud, long exp.
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Adventitious sounds
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crackles or rales, rhonchi, wheezes, friciton rubs
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Cause of rale or crackles
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passage of air through small airways that are sticky due to mucus fluid
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