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180 Cards in this Set
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Vital Signs Include:
& are influenced by: |
Temperature
Pulse Respirations Blood pressure (BP) Pain O2 saturation INFLUENCES (explain each): Age Gender & environment Lifestyle Race / heredity Exercise Medications Anxiety & Stress Pain Metabolism Circadian rhythms Hormones DZ, trauma, surgery History (Hx) & diagnosis (Dx) Height & weight Body position Smoking & lung function Neuro injury Hemoglobin (Hgb) Hypothermia |
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Technique for assessing vital signs... What's necessary?
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Gather equipment
Ask about any food, smoking or exercise in the last 15 – 30 minutes. Assure privacy Check client’s position |
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Types of equipment for Temperature assessment...
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Thermometer
- Digital, chemical - Tympanic - Temporal Artery - Glass * Being phased out d/t mercury * Oral/axillary * Rectal Probe covers, towel Gloves Lubricant |
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Temperature measurements..
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Gold standard –
Oral & tympanic (=) 98.6° F / 37° C Rectal - it is a degree higher (=) 99.5°F / 37.5°C Axillary - it is a degree lower (=) 97.7°F / 36.5°C Hypothermia (85° - 96° F) / (26.7° - 35.6° C) 96° F (=) 35.6°C 100° F (=) 37.8° C [low-grade] 101° F (=) 38.3° C Oral: - most common & convenient - (=) write as same degree - core temperatures - placement under tongue, 2-3 minutes (glass) - [time varies with digital – usually less than 1 min.] Tympanic / Temporal: - readily accessible, fast - (=) write as same degree - core temperatures - Tympanic - straighten the ear canal, hold with same hand as ear, a few seconds - Temporal - Use a light stroke across the forehead, immediate Axillary (& Tapes): - safest and most non-invasive - (+) write as plus a degree - (surface temp) - towel if sweaty - 5-9 minutes (glass) Rectal: - most reliable - Invasive - (-) write as minus a degree - DO NOT use with neonates - Insert ½ inch infant, 1 inch child, 1 ½ inch adult - 3-5 minutes (glass) |
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Pulse & Respirations (Resp) - Required equipment
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Watch with second hand
Stethoscope Alcohol wipes Gloves (Doppler if cannot hear) |
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Pulse Rates
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Adults – 60-100 bpm
Newborn – 110-180 & 120-160 (avg 140) Toddler [1-3 yo] – 90-140 & 80-150 (avg 115) Preschooler – 80 – 120 (avg 105) School- age – 70-115 (avg 95) Adolescent – 60-90 (avg 75) 30 seconds if regular (x2) 1 minute if irregular, or newborn Radial most common, over 3 yo Apical for under 3 yo 2-3 fingers over pulse, NOT thumb Normal ranges newborn infants: 100 to 160 beats per minute children 1 to 10 years: 70 to 120 beats per minute children over 10 and adults: 60 to 100 beats per minute well-trained athletes: 40 to 60 beats per minute |
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Pulse Rates and Rhythms (abnormal)
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Abnormal Rates:
tachycardia (=) > 100 bpm (adults) bradycardia (=) < 60 bpm (adults) Rhythm regular, irregular & combinations of reg & irreg ----------------→ dysrhythmia = irregular heart beat → When this happens you put them on Telemetry (electronic monitor), EKGs (electrocardiogram), Holter monitors (portable EKG basically) |
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Pulse Strengths and Equality (descriptions)
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[documentation]
Strength / volume / amplitude absent / weak / thready strong / full / bounding. Pulse deficit - radial & apical pulses do not match; document the difference between them (#). Grading Scale for Pulse Volume [Description] 0 – Absent (not palpable) 1+ - Barely palpable, weak, diminished 2+ - Normal 3+ - Full, increased 4+ - Bounding |
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Pulse sites
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Most common sites:
- Radial - Posterior tibial - Dorsalis Pedis - Apical Other: - Temporal - Carotid - Brachial - Ulnar - Femoral - Popliteal |
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Respirations (Resp) – definition & assessment
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Active / passive process
– exchange of O2 & CO2 – cellular level (alveoli) Watch, listen, feel - abdomen (boys and babies tend to breathe here), chest (girls and women tend to breathe here), back - Count for 30 seconds [if regular x 2 with 15 sec] - Possibly √ after checking pulse (morphine reduces breathing) Normal rate - Adults: 12 – 20 - Newborn: 30-60 Check for: Symmetry Nasal flaring Rib flaring or retractions Chest deformities Rate, rhythm, depth |
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Hawthorne Effect??
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People change their actions if they know they are being observed.
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Respiration – rate, rhythm, depth
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Resp - one (=) one inspiration & one expiration OR one inhalation & one exhalation
Rate (=) # per minute Rhythm - regular, irregular; labored (using accessory muscles, retractural) Depth – amt of air that moves with each breath; described as - shallow, deep Normal rates: Adults: 12 – 20 Newborn: 30-60 |
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Abnormal Respirations
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Tachypnea - >24 breaths per minute, rate regular, shallow
Bradypnea - <10 breaths per minute, slow, regular rate Apnea - absence of breathing Hyperventilation - abnormal increase in depth and rate Hypoventilation - abnormal decrease in depth and rate Cheyne-stokes - Periods of apnea throughout cycle (usually precedes death) Kussmaul - Deep, gasping breathing, attempt to blow off carbon dioxide (usually precedes death) Agonal - great pain in breathing (usually precedes death) |
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Blood Pressure (BP)... definition and measures
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Force of blood exerted from the heart (pump) under pressure; on artery walls
Measures / indicates: condition & function = cardiovascular (CV) status cardiac output (CO) = [the amount of blood discharged fromt he left or right ventricle per minute] peripheral vascular resistance = [a resistance to the flow of blood determined by the tone of the vascular musculature and the diameter of the blood vessels. It is responsible for blood pressure when coupled with stroke volume] blood volume blood viscosity = [blood stickiness] vessel elasticity (arteries, arterioles, veins & venioles) |
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Systolic/Diastolic and Blood pressure standards
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Top # over bottom (diastolic) # [120/80]
Systolic (=) peak (maximum) pressure of blood during blood pump exertion / ejection Diastolic (=) minimum pressure of blood still exerted during pump relaxation hypotension ↓ ↓ hypertension 90/60 120/80 140/90 So....... Range is 90-140 / 60-90 Orthostatic hypotension: BP lying, sitting, standing √ weak, faint, light head, unsteady positive test |
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Blood Pressure TECHNICAL Cuff Size info
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Bladder WIDTH should be 40 % of the circumference, or 20% wider than the diameter of the midpoint of the limb on which it is used.
Bladder LENGTH long enough to cover at least 2/3 of the limbs circumference. |
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Blood Pressure - Real Life Scenarios
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Cuff/bladder too narrow - ↑ BP reading
too wide - ↓ BP reading The American Heart Association recommends that the 2nd diastolic sound (the disappearance of sound in phase 5) be used as the index of the diastolic blood pressure for patients over age 13. Use the 1st diastolic sound (where muffling begins at phase 4) as the diastolic index for children age12 and under, for pregnant women and for patients with high cardiac output or peripheral vasodilation. All three sounds may also be recorded. Ex. 120/75/60 Syst/Diast/End = 120/75/60 Syst/Doppler Syst/Palpation |
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Documentation of Vital Signs graphic / flow sheet
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Always date, time, initial
Temperature – 98.6°F (O, A,T, R) Pulse – rate - # rhythm (regular, irregular), volume (absent – bounding), equality (bilateral), site Respiration – Rate # rhythm, depth (deep, shallow), quality / character e.g. labored Blood Pressure – reading (128/74) or (128/88/74) site (L arm), position (sitting) Palpate / auscultate Forearm – 5 in. below elbow, auscultate at radial artery Thigh – auscultate at popliteal artery Calf – above ankle, auscultate at dorsalis pedis Thigh & calf pressures are about 20-30 mmHg above brachial reading Forearm / radial Thigh / popliteal Ankle / dorsalis pedis Bilat mastectomy |
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Therapeutic Communication
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Is the use of communication for the purpose of creating a beneficial outcome for the client
Facilitates the establishment of the nurse client relationship Is purposeful and goal directed Has well defined boundaries Is client focused Is non judgmental Uses well planned selected techniques |
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Characteristics of a Therapeutic Nurse
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Empathy = understanding another person’s perception of the situation
Warmth = exhibiting positive behaviors toward the client Hope = help client look realistically at the future Trust = be honest call client by name to show respect |
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Establishing Therapeutic Communication
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Introduce self on initial contract
Explain own role Develop ground work for trust Determine client’s perception of problems Communicate at clients level of comprehension Other Tips: - Pay attention to the clients age, cultural background and health status - Be aware of the clients developmental stage and literacy level - Act calm and unhurried even if you are not - Evaluate the clients ability to communicate on a verbal level - Introduce yourself sitting down often encourages communication - Develop ground work for trust - Determine client’s perception of problems - Communicate at clients level of comprehension Examples of Therapeutic Techniques: - Offering self “ I’ll sit here with you” - Broad openings “Can you tell me more about that? How have things been going today? - Silence use eye contact - Open ended comments “Tell me about your pain? Tell me about your family? - Focusing directs conversation toward key topics. “You said you feel nauseous a lot” |
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Aggressive vs. Assertive Behaviors (by the Nurse) - Communication
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Assertive = When you stand up for your own rights without violating anyone else’s rights
Aggressive = humiliate, dominate, ok with violating rights to get what I want - Avoid Should and Shouldn’ts |
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Professional Boundaries and Group Dynamics and Values
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Professional Boundaries:
- Avoid close relationships - Act in the best interest of the patient - Protect yourself Group Dynamics - Delegate - Assertive - Roles - Time Values - Culture - Parents - School - Church - Experience Intrinsic (common to all mankind, basic needs) Extrinsic (originate from outside the person, extra values; example – professionalism) Value Actualization – When we acquire values |
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Hand washing - Importance
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Hospital Acquired = Nosocomial
- 2 million/year; 90,000 deaths/year (Catheters are the number one cause of nosocomial infections) Risk Factors for Nosocomial Infections - environment of microorganisms + many are antibiotic resistant + longer the stay, greater the risk - Invasive procedures - Health Care Workers (HCW) + poor hand washing practices |
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Just understand concepts of chain of infection
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- Infectious agent
- Reservoir - Portal of exit - Mode of transmission + direct transfer from one source to another + indirect transfer via a vehicle (contaminated equipment) - Portal of Entry - Susceptible Host |
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Basic Prevention Principles
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HANDWASHING (#1 factor in prevention of nosocomial infections)
Standard Precautions - Use of personal protective equipment gloves, gowns, masks/face shields |
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Standard Precautions - Tier 1 & Tier 2
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- Designed to reduce of transmission in recognized and unrecognized sources
- Combines Blood and Body Fluid Precautions and Body Substance Isolation - blood, all body fluids (except sweat), nonintact skin and mucous membranes, secretions and excretions whether they contain visible blood or not - defines when personal protective equipment is to be used Two tiered approach: First Tier = - Applies to ALL hospitalized patients regardless of infection status or diagnosis - Not limited to blood borne pathogens - Primary strategy to prevent nosocomial infections - Includes hand washing, handling of linen and patient care equipment, environmental cleaning and sharps disposal Second Tier = - disease specific precautions based on routes of transmission - airborne (droplets smaller than 5 microns) [Measles, TB, varicella] - droplet (droplets greater than 5 microns) [Meningitis, pneumonia, diptheria, rubella, etc.] - Contact [Staph, Hep A, RSV, wound and skin infections] Airborne – required to use special masks, they filter and are often called hepa masks Different masks for each one (droplet vs. airborne) |
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Hand washing - Purpose & When
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Purpose:
- deliver pathogen-free nursing care - prevent spreading pathogens to other patients - prevent cross-contamination - protect the nurse from the patient - prevents spreading pathogens to other employees Cross-contamination – let’s say a patient has a wound with one bacteria and a respiratory disease on another site, cross-contamination would be transferring a disease from one site (even on a patient) to a second site When : - Beginning and end of shift - Before patient contact; between contact - Before and after caring for wounds, dressings, specimens, linens - After contact with secretions, excretions - Before invasive procedures - Before med administration - After sneezing, coughing, nose blowing - After removing gloves - Before eating - After using restroom CDC Guidelines for alcohol-based cleanser: Appropriate UNLESS visibly soiled and may be used Prior to contact with patient - Before sterile gloving (non surgical procedures only) - After contact with intact skin - After contact with body fluids, secretions, mucous membranes, nonintact skin and dressings if not visibly soiled - After contact with inanimate objects (e.g. medical equipment) in immediate contact with patient Use soap and water before eating and after using restroom OSHA recommends soap and water every third time Alcohol based hand sanitizers do not kill norovirus or c. difficile Or swine flu Proper order for Gown Removal: 1) Untie at waist 2) Take off gloves 3) Untie at neck 4) Remove from shoulder 5) Mask/goggles 6) Wash hands |
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Cerebral Function
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The cerebrum of the brain is primarily responsible for a person's mental status.
Function: Thought processes; gray outer cortex houses higher mental functions and is responsible for perception and behavior. Frontal = Motor, speech, & goals Parietal = sensory processing Temporal = Sound interpretation, behavior, personality, and LT memory Limbic System = survival behaviors RAS (reticular activating system) = wakefulness |
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Cerebellar & Proprioception Function
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Proprioception = Where you are in space
Cerebellar = Balance |
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Sensory Function
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Understand the world around us through sensory input
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General Appearance Assessment - Neuro Cerebral
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General appearance:
- Grooming - poor hygiene; lack of concern with appearance; or inappropriate dress - Posture-body language (facial expression) - Emotional status - carelessness, apathy, loss of sympathetic reactions, unusual docility, rage reactions, or excessive irritability |
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Cognitive Ability Interview - Neuro Cerebrum
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Testing Cognitive ability - usually interview gives enough data to evaluate
Abstract thinking = ask for explanation of a fable, proverb, or metaphor - may indicate poor cognition, dementia, brain damage, or schizophrenia Analogies = describe simple analogies "how are peaches and oranges similar?" - may indicate a lesion of the left or dominant cerebral hemisphere Calculations = add 6's until 72.. - may indicate depression and diffuse brain disease Writing ability (drawing) = draw a picture, write name - may indicate dementia, parietal lobe damage (possibly by stroke), cerebeller lesion, peripheral neuropathy Motor Skills = sit down, hand through hair - may indicate cerebral disorder Attention span = this can be tested by calculation questions - may be related to fatigue, depression, delirium, toxic or metabolic causes that result in confusion Judgement = upon questions asked or information presented, patient should be able to evaluate and appropriately respond - may indicate mental retardation, emotional disturbance, frontal lobe injury, dementia, or psychosis Memory = relaying information from past - Immediate = recall of a few numbers or objects listed to patient; "dog, ball, shoe" - Recent or short term = Things you could evaluate, "did you have a long wait in the waiting room" - Remote or long term = "can you tell me who the president was before obama??" |
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Apraxia
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inability to translate an intention into action
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Mental status: states of consciousness - Neuro Cerebrum
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Conscious: awake, alert (oriented to time, place and person) [can write as oriented x3]
Confused = answers inappropriately, little disoriented, unsure about things, confused about what day it is but otherwise answers appropriately Lethargic = Drowsy and falls asleep quickly, but once aroused responds appropriately Obtunded = sleepy and still drowsy when awakened, decreased alertness and limited interest in the environment Stupor = Responsive only to vigorous and repeated visual, verbal, and painful stimuli, becomes unresponsive without stimuli Coma = Unresponsive even with painful stimuli (use Glasgow Coma Scale or agency scale) see Seidel page 86 Maximum score = 15 Lowest score = 3 -- bad |
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Speech and Language Assessment - Neuro Cerebrum
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Speech and language (intellectual function):
Voice quality (volume-soft, loud; nasally, clear, etc) - Dysphonia (disorder of voice volume, quality and pitch) may suggest a problem with laryngeal innervation Articulation (hesitant, stutters, repeats, etc) - Dysarthria (motor speech disorder) may suggest stroke, inebriation, cerebral palsy, and Parkinson disease Comprehension (follow commands) Coherence = patient's intentions or perceptions should be clearly conveyed to you - Circumlocution = word substitution to cover not remembering forgotten word, ex: Family went up, instead of saying up patient points finger upward - Perseveration = Repetition of a word, phrase, or gesture - Flight of ideas = All the words or sentences goes together, but they are out of order - Word Salad = words together that have no sense - neologisms = made up words Reading ability (careful!!!)- see chart on page 84 about Expressive (Broca) Aphasia = Knows what to say, but can't voice in words. Has telegraphic speech or impaired speech flow Receptive (Wernicke) Aphasia = Cannot understand; fluent speech but no understanding |
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Infants and Children Neuro Assessment
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Observe level of activity
Observe response to environmental stimuli Can they smile? Crying normal? Speech development where it should be? Memory appropriate for age? |
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Elderly Neuro Assessmen
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Mental status deteriates with age
Use tests developed for elderly |
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List Cranial Nerves, Know Pneumonics
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Cranial nerves - Stem from Brain Stem
I. Olfactory S - Smell II. Optic S - Sight III. Oculomotor M - eye muscle IV. Trochlear M - eye muscle (sup. oblique) V. Trigeminal B - face/teeth sensory, mastication muscle VI. Abducens M - eye muscle (ext. rectus) VII. Facial B - face muscle/sensory VIII. Acoustic S - ear IX. Glossopharyngeal B - tonsil, tongue, pharynx X - Vagus nerve B - heart, lungs, GI XI - Accessory nerve M - Sternocleidomastoid and Trapezius XII - Hypoglossal nerve M - tongue Oh, Oh, Oh, To Touch And Feel A Girl's Very Soft Hands Some Say Marry Money But My Brother Says Big Brains Matter Most |
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Reflexes - Neuro
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Reflex dependent on intact afferent neurons, functional synapses in the spinal cord, intact efferent neurons, functional neuromuscular junctions, and competent muscle fibers
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CN V (trigeminal) examination
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Inspect face for muscle atrophy and tremors
Motor = jaw opening, clenching, chewing (palpate) Sensory = corneal, eyelids, forehead, nose, mouth, teeth, tongue, ear, face - three areas for pain and touch sensation |
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CN VII (facial) Examination / CN IX (glossopharyngeal)
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Inspect = symmetry of facial features with various expressions
Motor = facial expressions except jaw (wrinkle forehead, show teeth, close eyes, whistle) Sensory = taste (anterior 2/3 of tongue) CN VII (anterior 2/3) & IX (posterior 1/3) |
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CN IX (glossopharyngeal) / X (Vagus) Examination
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Inspect = palate and uvula for symmetry with speech sounds and gag reflex
Motor = gag, swallow and speech Sensory = taste sour and bitter (Posterior 1/3) |
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CN X (Vagus) Examination
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Motor = gag, swallow (say “ah”)
Sensory = sensation behind ear, part of external ear |
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CN XI (Spinal Accessory) Examination
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Motor = turn head, shrug shoulders
sternocleidomastoid and trapezius |
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CN XII (hypoglossal) examination
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Motor = tongue movement for speech and swallow, press tongue against cheek
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Cerebellar Assessment - Neuro
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Finger to nose = dui test by police, alternate finger touching nose
Finger nose finger = have patient touch nose then nurse finger then move finger and repeat; slow to fast Heel to shin = scrape heel on shins; both sides Rapid alternating movements = pat thighs with hands, alternate supination and pronation; increase speed Finger to thumb = touch each finger to thumb both hands |
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Proprioception Assessment - Neuro
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Romberg = feet together, arms at side, eyes closed and check sway of patient (excessive, or slight)
- indicates cerebeller ataxia, vestibular dysfunction, or sensory loss Coordination (best done without shoes) - Natural walk - Heel to toe on line - Stand on each foot - Hop on each foot - Deep knee bend page 723 for unexpected gait patterns |
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Sensory Function Assessment - Neural
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Primary sensory function – p724
- Superficial tactile/Light touch (monofilament used in diabetic) = touch the skin with cotton or with monofilament; patient explains area touched and sensation felt - Pain (temperature and deep pressure tested only if pain abnormal) = after superficial fails, roll test tubes of hot and cold water against the skin; indicated temperature perceived and where - Vibrations (normally decreased in elderly) = stem of vibrating tuning fork against bony prominences; indicated when and where vibrations felt - Joint position = hold join to be tested and ask patient which way the joint was moved Cortical sensory function (Seidel, 724) ability of brain to interpret: Tactile discrimination: - Stereognosis = Hand the patient a familiar object and identify by touch only - Graphesthesia = draw a letter or number on patiant's palm; identify - 2 point discrimination = two sterile needles and alternate touching the patient's skin with one point or both points simultaneously at various locations - Extinction = simultaneously touch two areas on each side of the body with a tongue; as patient to tell you how many stimuli there are and where they are - Point location = touch and withdraw from patient's skin; ask patient to point to the area touched |
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Reflexes Assessments - neuro
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Deep tendon (DTR’s) =
Biceps Triceps Brachioradialis Patellar ankle 0 = no response 1+ = low normal 2+ = normal 3+ = more brisk than normal (not necessarily indicative of a problem) 4+ = brisk, hyperactive |
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Inspection
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Inspection (observation)--using eyes and nose
- must have adequate lighting - continues throughout the history taking - unhurried - expose area of examination Exam Technique Order: 1) Inspect 2) Palpate 3) Percuss 4) Auscultate (except when assessing abdomen) |
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Palpation
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Palpation- Feeling
- light (1 cm.) or deep (4 cm. - for doctors) touch using WARM hands/fingers - palmar surface of hands/fingers for position, texture, size, consistency, crepitus, pulses - ulnar surface for vibration, also ball of hand - dorsal surface for temperature Exam Technique Order: - Inspection - Palpation - Percussion - Auscultation |
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Percussion
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Percussion -striking one object against another to produce sound waves/vibration
- percussion tones are related to the density of the medium through which the sound wave travels - more dense tissue = quieter tone (liver, bone) - the more air (or less dense), the deeper and louder (stomach, air-filled lungs) Percussion technique = direct (use fist, finger) indirect (nondominat hand on surface and tap with dominant) - snap from wrist - sharp and rapid with fingertip - be consistent Exam Techniques Order: - Inspection - Palpation - Percussion - Auscultation |
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Auscultation
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Auscultation - listen for sounds with ears or stethoscope
- close eyes and focus on one sound - stethoscope on skin (clothing obscures) - diaphragm for high freq sounds - bell for low frequency sounds - quiet environment Exam Techniques Order: - Inspection - Palpation - Percussion - Auscultation |
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Kyphosis
Posture: elderly may appear slumped |
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Lordosis
Posture: toddler, pregnant, obese have exaggerated lordosis |
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Body Morphology
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Body Morphology
Ectomorphic - Tall, Lanky |
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Body Morphology
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Body Morphology
Endomorphic - short, stout |
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Body Morphology
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Body Morphology
Mesomorphic - normal build |
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Skin
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Skin - understand normal systems
Appendages of skin = - hair - nails - sebaceous glands (is the skin oily or not) - sweat glands: -- eccrine-open to skin surface-dissipate body heat -- apocrine-axilla and genital area |
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Skin Assessment
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Inspection =
- Color (pink to deep brown, pale, cyanotic, jaundice, erythema, hypopigmentation) - Condition (dry, moist, oily, intact, etc) - Appearance-presence of lesions Palpation = - Temperature (cool, warm) - Moisture (dry, moist) - Texture (smooth, coarse) - Turgor (elasticity) - Vascular changes - lesions (general abnormalities) |
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Cyanotic nailbeds
Cyanosis caused by lack of oxygen |
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jaundiced sclera and skin
mainly caused by liver damage |
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Erythema is redness = some skin conditions may be marked by this (bottom: circumoral erythema)
Pressure causes erythema to blanch, pressure doesn’t affect petichiae (or ecchymosis) |
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Hypopigmentation (not vitiligo)
An abnormal normal, areas of hypopigmentation. Doesn’t mean anything, just needs to be noted. |
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Xerosis
Condition: Skin condition is dry. |
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Skin Turgor
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Checking skin turgor
shows degree of elasticity which reveals hydration status - Sternum - Forearm - Infants = Abdomen (*chart is kids) |
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Petechiae = A vascular change-tiny pinpoint hemorrhages
Usually means sometime of clotting disorder or a serious condition Pressure causes erythema to blanch, pressure doesn’t affect petichiae (or ecchymosis) |
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Assessing Lesions
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Lesions Assessment
Color - brown - white - red (erythema) - yellow - blue - pink Associated history and behaviors (pruritis = burning or itching of skin, exposure to ?) Size - need to measure Distribution - generalized = lesions appear widely distributed or in numerous areas simultaneously - regional = lesions involve a specific region of the body - local = lesion appears in one small area Location (chest, back, arm, etc) Configuration - annular = round, active margins with central clearing - oval = ovoid shape - round/discoid = coin shaped (no central clearing) - linear = in a line - zosteriform = following a nerve or segment of the body - polycyclic = interlocking or coalesced circles - target lesion = pink macules with purple central papules - stellate = star shaped - serpiginous = snakelike or wavy line track - reticulate = netlike or lacy - morbilliform = measles like Border - discrete = well defined, able to draw a line around it with confidence - indistinct = poorly defined, have borders that merge into normal skin or outlying ill-defined papules - active = margin of lesion shows greater activity than center - irregular = non-smooth or notched margin - border raised above = center of lesion is depressed compared to the edge - advancing = expanding at margins Mobility Classification -- Primary; page 166-168 (macule, papule, patch, plaque, wheal, nodule, tumor, vesicle, bulla, pustule, cyst, telangiectasia) -- Secondary; page 169-171 (scale, lichenification, keloid, scar, excoriation, fissure, erosion, ulcer, crust, atrophy) |
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Annular lesion
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Discoid lesion
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maculopapular generalized distribution
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Linear – you’ll see with poison ivy sometimes or shingles
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Confluent = all run together
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Primary Skin Lesion
Macule - A flat, circumscribed area that is a change in the color of the skin ("mashed down") less than 1 cm in diameter Ex: freckles, flat moles |
Primary Skin Lesion
Patch - a flat, nonpalpable, irregular-shaped macule greater than 1 cm in diameter Ex: port-wine stains, vitiligo |
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Primary Skin Lesion
Papule - an elevated, firm, circumscribed area ("popped up") less than 1 cm in diameter Ex: wart |
Primary Skin Lesion
Plaque - elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter Ex: psoriasis |
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Primary Skin Lesion
Bulla - Vesicle greater than 1 cm in diameter; filled with clear serous fluid Greater than 1 cm Ex: Blister |
Primary Skin Lesion
Vesicle IF less than 1 cm in diameter filled with clear serous fluid |
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Primary Skin Lesion
Pustule |
Pustule - elevated, superficial lesion; similar to a vesicle but filled with purulent fluid
ex: acne |
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Primary Skin Lesion
Nodule - elevated, firm, circumscribed lesion; deeper in dermis than a papule 1-2 cm in diameter Ex: erythema nodosum |
Primary Skin Lesion
Tumor - elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis greater than 2 cm in diameter ex: neoplasms, benign tumor |
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Primary Skin Lesion
Wheal |
Wheal - elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter
Ex: insect bites, urticaria |
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Primary Skin Lesion
Cyst |
Cyst - elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material
ex: sebaceous cyst |
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Primary Skin Lesion
Telangiectasia |
Telangiectasia - fine, irregular, red lines produced by capillary dilation
ex: telangiectasia in rosacea |
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Secondary Skin Lesions
Scale - heaped-up, keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size Build up of keratinized skin; irregular, thick or thin, varies in size. |
Secondary Skin Lesions
Lichenification - rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surface of extremity Thickened epidermis secondary to persistent rubbing, itching, or skin irritation. ex: chronic dermatitis |
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Crust
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Secondary Skin Lesions
Crust- dried serum, blood, or purulent exudates; slightly elevated; size varies; brown, red, black, tan, or straw-colored Dried blood, serum or purulent exudate. ex: scab on abrasion, eczema |
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Secondary Skin Lesions
Keloid - irregular-shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing ex: keloid formation following surgery |
Secondary Skin Lesions
Scar - thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis ex: healed wound or surgical incision |
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Secondary Skin Lesions
Excoriation - loss of the epidermis; linear hollowed-out, crusted area Excoriation (linear loss of the epidermis, a scratch) and a fissure (linear loss of the epidermis but it is deeper, goes into the dermis) ex: abrasion or scratch |
Secondary Skin Lesions
Fissure - Linear crack or break from the epidermis to the dermis; may be moist or dry ex: athlete's foot |
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Secondary Skin Lesions
Erosion - loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla Erosion is uneven border and is only the epidermis ex: varicella |
Secondary Skin Lesions
Ulcer - loss of epidermis and dermis; concave; varies in size Ulcer is the same as erosion but it is deeper than erosion. It goes through dermis and can even go down into the bone ex: decubiti, stasis ulcers |
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Secondary Skin Lesions
Atrophy |
Secondary Skin Lesions
Atrophy - thinning of skin surface and loss of skin markings; skin translucent and paper-like ex: striae, aged skin |
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Nail Assessment
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ColorOpaque or translucent
Pink nail buds Capillary refill Thick think brittle?? Contour?? Smooth? Pitting?? Grooves?? transparency Thickness, shape, condition of surrounding tissue, nail attachment, texture, capillary refill |
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Clubbing - Greater 160 degrees
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Koilonychia-note spoon shape
seen in anemia |
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Onycholysis – you can separate plate
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Paronychia – inflammation and swelling of the cuticle (on the FINGER)
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Beau's Lines - seen in acute diseases
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Anonychia - absence of nails, result of trauma or genetics
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Acrocyanosis - Feet hands and lips sometimes turns blue. This is normal and goes away.
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Vernix caseosa - Cottage cheese covering on babies when they are born
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Lanugo – fine downy hair that covers babies
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Facial Milia – small white papules. Normal. Goes away. Plugged sebaceous glands.
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Erythema toxicum – normal. Goes away. Common rash.
Common rash of newborn; may be seen anywhere but palms and soles. Also called "newborn rash" or "flea bites" |
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Cavernous hemangioma - Collection of capillaries, as the baby grows most of the time they disappear
monitor as may continue to grow |
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Mongolian spot – patch, usually at the base of the spine or on the buttocks
May be mistaken for abuse Most prevalent in African-American, Hispanic, Native American and Asian population. Disappears by 1-2 yr. |
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Stork bites - Outgrow it normally
telangiectatic nevi |
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Nevus vascularis – immature capillaries. Usually go away.
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Port wine stain – flush with skin, patch, similar to strawberry mark but not raised, usually fades
Large, flat mass of blood vessels on the skin that deepens with exertion, emotions, exposure to temperature extremes. Port wine stain-Nevus flammeus |
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Café au lait – discoloration, can go away
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Harlequin phenomenon - Immature autonomic nervous system, means nothing
Reddening of one side, blanching of the other side with distinct line of demarcation. Seen first few days of life due to autonomic nervous system instability. No problem, disappears after few sec |
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Linea nigra – darkening, common
Also a common pregnancy skin change: Palmar erythema – redness of the palm, common (thenar) |
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Chloasma – butterfly discoloration on face, common, goes away, hormonal
"mask of pregnancy" |
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Striae
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Cherry angioma – papules, common as we age, usually there are a few
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Vitiligo - loss of pigmentation in patches
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Skin Tag - Common, usually in upper part of the body
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Lentigo (Senile lentigines) - flat, tan or brown
macules on sun exposed areas pronounced “Len-tie’-go”, “lentij in knees” |
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Senile purpua – bleeding below the skin, more noticeable in the elderly because they lose that dermal layer so their skin is paper thin and you can see it
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Xanthelasma – accumulation of lipids
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Actinic Keratosis – Chronic sun damage and has malignant potential; Scaly, rough on the top, usually in an area that has been open to sun
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Seborrheic keratoses –raised warty lesions on face, shoulders, trunk with irregular border
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Spider angiomas - bright red, small; visible dilated vessels
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Beard Folliculitis
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Antipyretic
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an agent that reduces febrile temperatures
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Arteriosclerosis & atherosclerosis
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an arterial disease characterized by inelasticity and thickening of the vessel walls with lessened blood flow
atherosclerosis = accumulations of lipid-containing material within the internal surfaces of blood vessels |
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autoregulation
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the intrinsic ability of an organ or tissue to maintain blood flow despite changes in arterial pressure
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febrile
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feverish, increased body temperature
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hypervolemia/hypo
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abnormal increase in the volume of circulating body fluid/decrease
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infarction
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an area of the tissue in an organ or part that undergoes necrosis (death) after cessation of blood supply
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ischemia
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local and temporary hypoxia (no oxygen) due to obstruction of the circulation to a part
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normotensive
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a normal tone, tension or pressure, as in normal blood pressure
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pyrogen
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any substance that produces fever
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sonorous
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loud breathing
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stertorous
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loud, noisy breathing
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thermoregulation
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the body's physiological function of heat regulation to maintain a constant internal body temperature
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Valsalva's maneuver
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attempt to forcibly exhale with the glottis, nose, and mouth closed, producing an increased intrathoracic pressure.
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Bigeminal pulse
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a regularly irregular pulse where every second beat has a decreased amplitude
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bounding pulse
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pulse pressure is increased. it is felt as a slapping against the fingers because of the rapid upstroke and quick downstroke
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normal pulse (+2 diminished, 3+ strong??)
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pulse is smooth and rounded and is felt as a sharp upstroke and gradual downstroke.
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PMI
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apical pulse or point of maximum impulse; palpated at fifth intercostal space, left midclavicular line. pulse occurs with contraction of left ventrical.
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weak or thready pulse
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pulse pressure is diminished. it is smooth and rounded, but is felt as a gradual upstroke and prolonged downstroke.
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Meningeal signs - Neuro Assessment
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Kernig sign - flex the leg at the knee and hip when the patient is supine, and then attempt to straighten the leg. observe for pain in the lower back and resistance to straightening leg
Brudzinski sign - flex the neck and observe for involuntary flexion of the hips and knees May show signs due to meningitis |
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Infant Reflex - Neuro
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Moro reflex – diminishes at 3-4 mos; absent at 6 mos
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Infant Reflex - Neuro
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Rooting reflex –usually disappears at 3-4 mos but may
be present up to 12 mos |
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Infant Reflex - neuro
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Sucking reflex – present throughout infancy
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Infant Reflex - Neuro
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Extrusion
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Infant Reflex - neuro
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Palmar grasp- up to 3 mos
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Infant Reflex - Neuro
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Plantar grasp – lessens by 8 mos
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Infant Reflex - Neuro
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Babinski reflex
Normal up to 16 months |
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Infant Reflex - neuro
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Tonic Neck Reflex - "Fencing"
by 2-3 months |
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Infant Reflex - Neuro
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Trunk incurvation or gallant reflex
disappears by 4 weeks |
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Infant Reflex - neuro
Placing reflex: seen birth to six weeks. Touch dorsum of foot to table edge and infant lifts foot and places it on table. |
Infant Reflex - neuro
Sometimes called “stepping or walking or dance reflex”. Disappears by 3-4 weeks, may still be present at 3 mos. |
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Infant Reflex - Neuro
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Crawl Reflex : Disappears at 6 weeks
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hyperopia = farsightedness, a refractive error in which rays of light enter the eye and focus behind the retina
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myopia = nearsightedness, a refractive error in which rays of light enter the eye and focus in front of the retina
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presbyopia = impaired near vision in middle-age and older adults, caused by loss of elasticity of the lens and associated with the aging process
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Macular degeneration = blurred central vision often occurring suddenly, caused by a progressive degeneration of the center of the retina (common over age 50)
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retinopathy = a noninflammatory eye disorder resulting from changes in retinal blood vessels. it is a leading cause of blindness
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strabismus = a congenital condition in which both eyes do not focus on an object simultaneously; these eyes appear crossed
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Cataracts = an increased opacity of the lens, which blocks light rays from entering the eye.
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Glaucoma = intraocular structural damage resulting from elevated intraocular pressure. obstruction of the outflow of aqueous humor causes this.
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External Eye Structure Assessment (Basics)
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Observation
- Evenly Spacing, Well alignment & symmetry (even) Eyebrows - May show endocrine disorders - should be full Lids and lashes - equal palpebral fissures (top/bottom & side/side) - Do the lids close completely? (endocrine disorders cause non-closing eye lids) - Distribution and condition of lashes (no drainage on eye lashes) - with eyes open; Upper Lids should overlap irises just a tad - are the lids equidistant? Corneal reflex (CN 5) – Blink response [Don't do generally] - may scratch the cornea Lacrimal Apparatus - inspect puncta for drainage, redness. - Press with gloved index finger or cotton applicator - Newborns- [sometimes tear duct is plugged], [check eye occiput line, position of ears] Conjunctiva (pull down to check while client looks up. No need to evert lid.). - Palpebral = lines lids - Bulbar = covers sclera and contains many vessels that may cause redness. [can be seen with blood-shot eyes] Iris - should be flat, round, note color Pupil - Pupils Equal Round React to Light (PERRL), Pupils Equal Round React to Light & Accomodation (PERRLA); CN III - size (normal is between 2-6 mm) - smaller size in infants, elderly, and farsighted - Larger size in nearsighted. Miotic = under 2 mm Mydriatic = over 6 mm - consensual (light form one eye and other reacted) - aCCommodation - do they converge and constrict? Inspect depth of anterior chamber. - Cornea should be transparent. - Checked with tangential light - A shadow indicates a narrow chamber which suggests glaucoma |
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Entropion = inward turned eyelid
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Ectropion = Outward turned eyelids
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Brushfield’s = spots at periphery (seen in Down’s)
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Tangential light test
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Tangential light test
Inspect depth of anterior chamber. Cornea should be transparent. Checked with tangential light A shadow indicates a narrow chamber which suggests glaucoma |
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Distant Vision
Snellen Eye Chart - 20/20 - normal vision - Numerator is the distance the patient is from the chart - Denominator is the distance one with NORMAL vision can read the letters. Test both eyes, then R, then L |
Near Vision
Rosenbaum Eye Chart - handheld eye chart |
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Allen cards or picture charts for preschoolers
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Tumbling E chart
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Peripheral vision or visual fields
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Peripheral vision or visual fields
confrontation test (assumes tester has normal fields). - a crude test - normal is about 90 degrees temporal |
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Extraocular muscle (EOM) function or tests of CN III, IV, VI
Cover-Uncover |
Cover-uncover
- Determines muscle function & alignment - may reveal latent Strabismus Strabismus – the visual axes of the eyes are not directed at the same point. Tropias – Eye deviations from muscle imbalances |
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Anisocoria
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Anisocoria = unequal pupil size (in each eye)
- seen in 5% of population - (20% of population according to Seidel). |
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Extraocular muscle (EOM) function or tests of CN III, IV, VI
Corneal Light Reflex (Hirschberg's test) |
Corneal light reflex (Hirschberg’s test)
- Determines eye alignment - shine penlight at bridge of nose from 12 - 15 inches |
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Extraocular muscle (EOM) function or tests of CN III, IV, VI
Checking for Strabismus and muscle imbalances |
Have client focus on object and go in "H"
Six cardinal positions of gaze. - - - Check for nystagmus--normal when eyes go lateral LR6 SO4 , all others are CN III. |
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Ptosis = a drooping of the upper eyelid
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Xanthelasma = lipid build up
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Entropion or Ectropion = eye lid folds inward, eye lid folds outward
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Hordeolum = stye
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Blepharitis = inflammation of eyelash cuticles
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chalazion = mybomen glands that line eye become blocked by bacteria
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Pterygium - An overgrowth of conjunctiva that extends over the cornea
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Arcus Senilis = white ring at periphery
- sclera-normally white - cornea-transparent, smooth, shiny-examine by shining light from several angles |
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Iris Coloboma = A cleft or gap in the eye that happens in utero.
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Visualize the “red reflex” (this is the retinal background)
Slowly move closer to the patient, keeping the red reflex in sight. Adjust the focus as needed as you look for: retinal vessels-4 sets with. follow a vessel to the disc (toward the nose) - optic disc -1.5 mm, yellow to pink in color, note physiologic cup (depressed center of the disc) - macula – Lastly, have patient look into the light; 2DD temporal to optic disc |
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Ear Alignment ↑
Inspection of External Ear |
External ear
- Inspection (symmetry, color, nodules, cysts, tophi) - Palpation (tenderness, nodules) - Check ear alignment (infants), position - Inspect external auditory canal for redness, discharge, swelling, etc.- describe appearance and odor -vPalpate mastoid |
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Inner Ear Examination
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Internal/ tympanic membrane
- Straighten canal (adult vs child) - normal is translucent, pearly, grey - - Bulging, red, retracted = abnormal - locate landmarks - light reflex (R ear @ 5 o’clock; L ear @ 7 o’clock) - - umbo, malleus - some cerumen in canal is normal!! |
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Auditory Acuity - CN VIII
Tests |
Auditory acuity CN VIII
- test one ear at a time - Whisper test 1-2 feet away-should hear 50% of words - ticking watch (test on self first)-start 5 inches from ear; tests high frequency |
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Tuning fork tests
- used to test for conductive or sensioneural hearing loss Rinne tests bone and air AC>BC (Air Conduction is Greater than Bone Conduction ) |
Tuning fork tests
- used to test for conductive or sensioneural hearing loss Weber tests bone conduction Should be Equal in both sides - if it lateralizes then it will lateralize in the ear that has problems |
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Other Tests for Hearing
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Audiometry = headphones “yes” “no” different frequencies
Tympanogram = print out like ekg repot and shows the tympanic membrane report, measures movement of tympanic membrane Crib-o-gram = infants response to different sounds Startle reflex in newborn = a first guess of hearing problems |
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Nose Assessment - CN I
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Sinuses (frontal and maxillary)
- Swelling, pain on palpation External -Size, shape, skin, nares (flaring, narrowing?) - discharge Internal - Use flashlight or speculum - Septum, mucosa, patency (openness) |
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Oral Cavity Assessment
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- Lips
- Buccal mucosa, teeth, gums Tongue - Inspect size, coating, color, - ulcerations |
