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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 |
Created by:
landonmc
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