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Combined Sets
MISC+MISC 2+LABS VALUES
| Question | Answer |
|---|---|
| The integumentary system includes | Skin, Hair, Nails, Sweat Glands |
| History & Risk factors for skin disorders includes | Exposure to Sun or radiation, personal hygiene, medications & allergies |
| Risk factors for skin breakdown includes | Nutritional status, mobility, sensory, and moisture |
| Assessment of Integumentary system | Color, texture, moisture, turgor, and temperature |
| Urgent Assessments | Severe dehydration, cyanosis, impaired skin integrity, burns and acute trauma |
| Wounds Assessments include | Location, size, color, texture, drainage, margins, surrounding skin, and healing status |
| Older Adult Factors | Decreased elasticity, decreased eccrine gland function, decreased nerve endings in skin, decreased nail growth and nails become more flat, dry and brittle, decreased sensation, decreased sweat |
| Ecchymosis | Purpura-Flat Purple Lesions |
| Hematoma | Collection of blood outside of the blood vessels but under the skin |
| Bruise | Discolored skin on the body, rupturing underlying blood vessels. |
| Diseases that cause ecchymosis | Leukemia, Acute Renal Failure, Cancer |
| Braden Scale | Used to assess skin breakdown by totaling scores from six sub-scales: sensory, perception, moisture, activity, mobility, nutrition, and friction. Each subscale is scored from 1-4 with 1 indicating the most risk and 4 indicating the least |
| Norton Scale | Used to assess skin breakdown by totaling scores from five sub-scales: Physical condition, mental condition, activity, mobility, and incontinence. Each is scored with the higher number indicating the least risk and lower number indicating the most risk |
| Cultural Considerations of Assessment | Skin color, eye shape, nose, lips |
| Facial Nerves | CNV (Trigeminal) & CNVII (Facial Nerve) |
| TrigeminalCNVII | Have patient squint, puff out cheeks or smile, and assess for symmetry |
| FacialNV | Provides sensory and motor function to the face. Touch face with cotton ball. Ask patient to clench teeth or bite down like chewing |
| Salivary Glands | Parotid, Submandibular, Sublingual |
| Sternomastoid Muscle | Head rotation and flexion |
| Trapezius | Extend and turn head, move shoulders |
| CN XI Spinal Nerve | Have patient shrug shoulders and turn head |
| Malignancy of Lymph nodes | Hard, rubbery, or does not move. Or appeared for no reason |
| Cervical Lymph Node Enlargement | Viral illness |
| Posterior Cervical Lymph Node Enlargement | Mono |
| Anterior Cervical Lymph Node Enlargement | RSV, Upper Respiratory Infections |
| Auricular Lymph Node Enlargement | Ear Problems |
| Snellen-Visual Acuity Test | Client is 20 ft away, covers one eye at a time. Top number = distance, bottom =smallest line the patient can read |
| Jager Card Visual Test | Held in the hand. The smallest print a patient can read determines visual acuity |
| Confrontation Test | Visual field testing involving the patient looking directly at your eye or nose and testing each quadrant of peripheral vision. |
| Normal Pupil Size | 2-4 mm in light, 4-8 mm in dark, 3-5 mm resting |
| Extraocular Muscles | Assessment of symmetrical movements of the eyes in all nine cardinal fields of gaze |
| PERRLA | Pupils, Equal, Round, Reactive, Light, Accommodate |
| Otoscope Technique in Adults | Pull auricle up, back and slightly away from head |
| Otoscope Technique in Children | Pull down and back closer to ear lobe |
| Whisper Test | Plug opposite ear, have mouth not visible to client. Then have client repeat what you said |
| Rinne Test | Assess conductive hearing. The client will hear the sound by air conduction from air near the ear longer than hearing through vibrations |
| Weber Test | Assess unilateral hearing loss by placing a vibrating tuning fork in the center of the head. |
| CN IX Glossopharyngeal | Have patient say ah or kah. Uvula should rise equally |
| CN X Vagus | Testing gag reflex have patient say kah |
| CN XII Hypoglossal | Have patient stick out tongue and move it from side to side |
| Any white spots on the throat/tonsils indicates | Infection |
| The nose | Warms, moistens, filters inhaled air |
| CN I Olfactory | Sense of smell |
| Lymph Nodes | Preauricular, Posterior Auricular, Occipital, Submental, Submandibular, Jugulodigastric, Superficial Cervical, Deep Cervical, Posterior Cervical, Supraclavicular |
| Assessing the thyroid gland | Stand Behind the patient, have them tilt head slightly, Palpate thyroid, cricoid cartilages, and thyroid isthmus |
| Thyroid Dysfunction is common | Over the age of 60 |
| Lateral Flexion of the Neck | Ear to shoulder |
| Flexion less than this is a cause for concern - this is the normal flexion | 45 degrees |
| The upper airways | Warm, moisturizes, and transports air |
| The Lower Airways | Provide oxygenation, and ventilation |
| Pairs of ribs | 12 |
| Thoracic Nerves are T1-T12, and dermatomes | Phrenic nerve, intercostal nerves |
| Four functions of Respiration | Supply O2 to body for energy, remove CO2, maintain homeostasis of arterial blood, maintain heat exchange |
| Hypercapnia | Excessive amounts of CO2 in blood |
| Hypoxemia | Abnormally low concentration of O2 in blood |
| Respiration is controlled by the | Respiratory center in brainstem and changes in CO2 and O2 in blood |
| Inspiration | Diaphragm contracts and lungs move downward |
| Expiration | Diaphragm relaxes, and lungs move up |
| Anterior Landmarks | Suprasternal (jugular) notch, sternum, sternal angle, costal angle |
| Anterior Reference Lines | Midsternal, Midclavicular, Anterior Axillary |
| Suprasternal (jugular) notch | Landmark for where ribs start |
| Posterior Landmarks | Vertebra Pominens, spinous processes, inferior border of scapula, 12th rib. |
| Posterior Reference Lines | Vertebral Line (Midspinal Line) and Scapular Line |
| Right side of lungs | Contains 3 lobes |
| Left side of lungs | Contains 2 lobes |
| Barrel chest is present in | COPD, asthma, cystic fibrosis |
| Kyphosis | Round back or hunchback |
| Scoliosis | Bent sideways |
| Symmetrical Expansion | Place hands at the 10th rib -- place fingers parallel to each other and slightly apart -- have patient breathe in deeply. -- Assess for expansion of rib cage and contraction along with equal separation of thumbs |
| Tactile Fremitus | Use base/ball of hand and touch persons chest -- have patient state words 99. -- assess for vibrations |
| Whispered Pectoriloquy | Patient quietly says 99, and sound should be inaudible |
| Egophony | Client states letter e, which should sound like e |
| Bronchophony | Client states 99 which should provide inaudible sounds. If it is clear test is positive |
| Hemoptysis | Coughing up blood |
| Dyspnea | Difficult or labored breathing |
| Orthopnea | SOB while lying flat |
| Paroxysmal nocturnal dyspnea | Attacks of SOB and coughing when sleeping |
| Apnea | Patient stops breathing |
| Bradypnea | Abnormally slow breathing |
| Tachypnea | Rapid breathing |
| Montgomery Glands | Combination of milk glands and sebaceous glands secreting small amounts of breast milk and mainly produce natural, oily substances to clean and lubricate areola. |
| Gynecomastia | Enlarge breast tissue in men |
| Sodium (Na+) | 135-145 mEq/L |
| Potassium (K+) | 3.5-5.0 mEq/L |
| Calcium (Ca++) | 8-10 mg/dL |
| Magnesium (Mg++) | 1.8-2.4 mg/dL |
| Phosphorous (PO4) | 2.5-4.5 mg/dL |
| Creatinine (Cr) | 0-1 mg/dL |
| Blood urea nitrogen | 10-30 ug/dL |
| Ph | 7.35-7.45 |
| PaCO2 | 35-45 mmHg |
| PO2 | >80 mmHg |
| HCO3 | 22-26 mmHg |
| SaO2 | 90-100 % |
| Red blood cells (RBC) Males | 4.6-6.2 mil/mm3 |
| Red blood cells (RBC) Females | 4.2-5.4 mil/mm3 |
| White blood cells (WBC) | 4800-10,800 mm3 |
| Hemoglobin (Hgb) Males | 13-18 g/dL |
| Hemoglobin (Hgb) Females | 12-16 g/dL |
| Hematocrit (Hct) Males | 42-52% |
| Hematocrit (Hct) Females | 37-48% |
| Glycosolated Hemoglobin (Hgb A1C) | 5% (up to 7% in diabetic) |
| Erythrocyte Sedimentation Rate (ESR) | <20 mm/hr |
| Bleeding time | 4-7 min |
| INR | 2.0-3.0 |
| Platelets | 150,000-450,000 /mm3 |
| Prothrombin time (PT) | 11-14 sec |
| Partial thromboplastin time (PTT) | <40sec |
| Albumin | 3.8-5.0 g/dL |
| Ammonia | 11-35 umol/L |
| Total bilirubin | 0-1.5 mg/dL |
| Total protein | 6.0-8.0 gm/dL |
| Urine Specific gravity | 1.010-1.030 |
| Urine Ph | 4.5-7.5 |
| Therapeutic Digoxin level | 0.8-2.0 ng/mL |
| Therapeutic Lithium level | 0.8-1.2 mEq/L |
| Four negatives in Urine | Glucose, RBC, WBC, Albumin |
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