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