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3060 Test 1

General Survey, Assessment, VS, Skin, Pv and lymphatics

QuestionAnswer
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
Created by: landonmc