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3060 Test 1
General Survey, Assessment, VS, Skin, Pv and lymphatics
Question | Answer |
---|---|
BMI Norms | 19-25 |
BMI Anorexia | 16 or below |
BMI Overweight | 25-29 |
BMI Obese BMI Extreme Obesity | 30-39 40 above |
When are VS assested | Upon admission, Changes in condition, Before/After medication intake, before procedures |
who can take VS | RN, LPN, UAP (only RN can assess or if pt is unstable) |
Sequence for inspecting a Preschool Child | thorax, abdomen, extremities, and genitalia first head, eyes, throat, nose last |
Sequence for inspecting School-age Child | progress from head to toe |
Normal range for temperature | 96.5F-99.1F 35.8C-37.3C |
Factors that raise Temperature | Basal metabolic rate, Activity, Epinephrine/Thyroxin, Fever |
Factors that lower Temperature | Radiation, Convection, Conduction, and Vaporization |
Pyrexia | Fever 100.4F-104.9F |
Hyper-pyrexia | 105F or above |
How long do you wait for oral temp after eating/drinking? Smoking? | 20 mins 2 mins |
Which temp procedure is preferred by newborns? | Axilla |
Procedure for Tympanic temp on Adults? Children under 3? | Pinna pulled up and back Pinna pulled down and back |
Normal pulse range for Adult? 10-teen? 5-8? 1 year? | 50-100; 50-100 75-120; 80-140 |
Bradycardia | below 50 |
Tachycardia | Above 100 |
Normal respirations for Adult? 16 yr old? 8-10? 1 yr? | 10-20; 12-20 20-26; 20-40 |
What is pulse pressure? | Difference between the Diastolic and Systolic pressure |
Factors that affect BP? | weight, medicines, genetics, gender, race, stress, pain, diet |
Normal BP range for Adults? | 120/80 |
BP prehypertension | 120-139/80-89 |
BP Stage I hypertension | 140-159/90-99 |
BP Stage II hypertension | >160/>100 |
BP hypotension | 85-110/70-79 |
Orthostatic hypotension | drop in diastolic pressure when sitting up |
Auscultatory gap | a brief time period(30-40 mm hg) when sounds disappear common with hypertension |
Do NOT take BP on pt's arm with: | dialysis graft, PICC line, IV line, lymph node removal, recent surgery or injury |
Order of Assessment: | Inspection, Palpation, Percussion, Auscultation |
Difference between Percussion:Direct? Indirect? | percuss on body part percuss on hand over body part |
Stethoscope: Diaphragm sounds? Bell Sounds? | High pitched sounds; hold tightly on skin Low pitched sounds; hold gently on skin |
Alopecia | hair loss |
Annular | circular shape to skin lesions |
Bulla | elevated cavity containing free fluid; >1cm |
Confluent | skin lesions that run together |
Crust | thick, dried-out exudate left on skin when vesicles/pustules burst or dry up; i.e. scab |
Cyanosis | blue color on skin due to deoxygenated blood |
Erosion | scooped out, shallow depression in skin i.e. ruptured vessicle |
Erythema | intense redness of the skin due to excess blood in dilated superficial capillaries; i.e. fever |
Excoriation | self-inflicted abrasion on skin; i.e. scratching |
Fissure | linear crack in skin extending into dermis i.e. tinea pedis (ringworm of the foot) |
Furuncle | suppurative inflammatory skin lesion due to infected hair follicle; i.e. boil |
Hemangioma | skin lesion due to benign proliferation of blood vessels in the dermis |
iris | target shape of skin lesion |
Jaundice | yellow skin to lesion, palate, and sclera due to excess bilirubin |
Keloid | hypertrophic scar elevated beyond site of original injury |
Lanugo | hair that covers child in utero |
linea nigra | line down belly of pregnant women |
keratin | tough, fibrous skin protein i.e. hair |
melanin | gives brown tone to skin and nails; skin color |
striae gravid arum | stretch marks |
What is skin color derived from? | Melanin, carotene, and vascular bed |
vellus hair | light, faint hair that covers the body |
terminal hair | dark, thicker hair that grows on scalp, eyebrows, armpit, and pubic area |
sebaceous glands | sebum lubricates hair and skin and helps with water retention; abundant on forehead, scalp, face, and chin |
sweat glands | Eccrine: sweat Apocrine: armpits and pubic area |
vernix caseosa | thick, cheesy substance made up of sebum and shed epithelial cells |
chloasma | brown patches face in pregnant women |
melasma | patchy tan to dark brown discoloration of the face |
Pseudofolliculitis | "razor bumps" or "ingrown hairs" |
macule | flat skin lesion with only a color change; <1cm i.e. freckle |
moles: ABCDE | Asymmetry, Border, Color, Diameter(>6mm), Enlargement |
Nail profile sign: Normal? Curved Nail? Early clubbing? | 160 degrees >160 degrees >180 degrees; nail bed elevates |
mongolian spot | hyper pigmentation in darker skinned newborns |
mobility | pinching up, how easy does it pinch up |
turgor | how easy does the pinched skin go back in place |
Senile Lentigines | liver spots |
acrochordons | overgrowths of normal skin that form a stalk and are polyp-like i.e. "skin tags" |
patch | macule >1cm |
Papule | palpable, superficial thickening <1cm i.e. mole, wart |
Wheal | raised red skin lesion due to interstitial fluid i.e. insect bite, allergic reaction |
Urticaria | intensely pruritic, light colored (pallor) wheal i.e. hives |
Vesicle | elevated cavity containing free fluid, >1cm i.e. blister |
Pustule | Turbid fluid (pus) circumscribed and elevated i.e. acne |
tinea capititis | scalp ringworm, scaly |
tinea corporis | ringworm of the body, scaly |
Lyme Disease | spirochete bacterium in ticks; bull's eye red macular or rash fades in 4 weeks |
Psoriasis | scaly, red patch, with silvery scales on top |
Herpes Simplex | lesion erupts with tight vesicles then pustules then ulcers i.e. cold sore |
Herpes Zoster | small, grouped vesicles then pustules then crust i.e. shingles |
Melanoma | irregular, notched borders. usually brown; can be tan, black, pink-red, purple, or mixed pigmentation i.e. skin cancer |
Hirsutism | excessive hair in females face |
Paronychia | red, swollen, tender, inflammation of the nail folds |
Beau's line | transverse furrow or groove in nail bed i.e. nail trauma |
Splinter hemorrhages | red-brown linear streaks, embolic lesions |
right lymphatic duct | empties into the right subclavian |
thoracic duct | empties into left subclavian |
Functions of the lymphatic system | to conserve fluid and plasma proteins, immune system that fights disease, and absorb lipids |
Functions of the spleen | destroy old RBC, produce antibodies, store RBC, filter microorganisms |
Function of tonsils | respond to local inflammation |
Function of thymus | developing T lymphocytes of the immune system in children |
arteriosclerosis | peripheral blood vessels grow more rigid with age |
atherosclerosis | fatty plaque deposits in arteries |
Homan's sign | calf pain with flexing of the knee |
Raynaud's Phenomenon | episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress |