sscc test 2 Health Assessment
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Created by:
Lnlindy on October 3, 2009
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Classes:
NURS 3510: Health Assessment, Columbus Adult Class 2012
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218 terms
Terms | Definitions |
|---|---|
 Stage 1 Pressure Ulcer | skin is unbroken, red, and there is no blanching |
| Stage 2 Pressure Ulcer | skin is broken, superficial skin loss involving the epidermis or dermis, lesion resembles a vesicle, erosion, or blister |
| Stage 3 Pressure Ulcer | pressure area involves epidermis, dermis, and sub-Q tissue, ulcer resembles a crater, hidden areas of damage may extend through sub-Q tissue beyond borders of external lesion but not through fascia |
| Stage 4 Pressure Ulcer | pressure area involves epidermis, dermis, sub-Q tissue, bone, and other support tissue, resembles a massive crater with hidden areas of damage in adjacent tissue |
| Epidermis | Outer layer of skin composed of 4 layers: stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. Composed of keratin which is a scleroprotein that's insoluble in water |
| Epidermis | skin layer almost completely replaced ever 3-4 weeks |
| Stratum germitativum | the only epidermal layer to undergo cell division and contain melanin and keratin forming cells |
| Dermis | Inner layer of skin, connected to epidermis by papillae which form base for visible swirls that provide unique patterns for fingerprints |
| Dermis | well vascularized connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels |
| Dermis | origin of hair follicles, sebaceous glands, and sweat glands |
| Subcutaneous | loose connective tissue containing fat cells, blood vessels, nerves, and remaining portion of sweat glands and hair follicles |
| subcutaneous | assists with heat regulation and contains vascular pathways for supplying nutrients and removing waste products |
| skin | physical barrier that protects underlying tissue and sturctures from microorganisms, physical trauma, ultraviolet radiation, and dehydration |
| skin | vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis |
| skin | provides individual identity to a person's appearance |
| fingernails | hard, transparent plates of keratinized epidermal cells that grow from root underneath skin fold called the cuticle; nails are smooth and firm and the nail plate shoudl be firmly attached to the nail bed |
| fingernail | normally at a 160 degree angle between nail base and skin; fingernail changes may be seen in systemic disorders such as malnutrition or with local irritation ( nail biting) |
| nail pitting | signs of psoriasis |
| early clubbing | 180 degree angle with spngy sensation |
| late clubbing | greater than 180 degree angle |
| signs of hypoxia | early and late clubbing |
| spoon nails | may be present with iron deficiency anemia |
| thickened nails | may be caused by decreased circulation; dark skinned people have thicker nails |
| older clients nails | may appear thickened, yellow, and brittle because of decreased circulation in extremities |
| paronychia (inflammation) | indicates local infection |
| onycholysis | detachment of nail plate from nail bed and is seen with infections or trauma |
| beau's lines | caused by acute illness, actual indentions on nails |
| capillary refill | test by pressing nail tip briefly and watching for color change ( normally pink tone returns immediately to blanched nail beds when pressure is released) |
| normal refill time | within 2 seconds, used to assess cardiac output |
| slow capillary refill time | greater than 2 seconds, occurs with respiratory or cardiovascular disease that causes hypoxia |
| capillary refill | time it takes for re-perfusion to occur after circulation has been stopped; measure time it takes for color to return to the tissue |
| A of skin cancer | asymmetry |
| B of skin cancer | borders that are irregular ( uneven or notched) |
| C of skin cancer | color |
| D of skin cancer | diameter exceeding 1/8 to 1/4 inch |
| E of skin cancer | elevation and enlargement |
| steroid therapy skin effects | very thin skin |
| jaundice assessment | yellow skin tones, from pale to pumpkin, in sclera, oral mucosa, palms, and soles |
| to assess skin | inspect general skin coloration, inspect for color variations, check for skin integrity, inspect for lesions |
| normal skin assessment | evenly colored skin tones without unusual or prominent discolorations. slight or no odor of perspiration, depending on activity |
| Small amounts of melanin | common in whiter skins |
| large amounts of melanin | common in olive and darker skins |
| carotene | accounts for a yellow cast |
| older clients skin | pale due to decreased melanin production and decreased dermal vascularity |
| vitilgo | complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices |
| albinism | generalized loss of pigmentation |
| dark skinned clients may have | lighter-colored palms, soles, nai beds, and lips. freckle like or dark streaks of pigmentation are also common in the sclera and nail beds |
| white skinned clients have | darker pigment around nipples, lips, and genitalia |
| normal lesions | moles, freckles, birthmarks... |
| palpate skin to assess | texture, thickness, moisture, temperature, mobility, turgor, and edema |
| normal palpation of skin | smooth, even, thin but calluses are common on areas of the body that are exposed to constant pressure, moist to dry depending on area, warm temp, pinches easily and immediately returns to original position |
| older client's skin palpation | may feel dryer than a younger client's skin because sebum production decreases with age, loses turgor because of a decrease in elasticity and collagen fibers, sagging or wrinkled skin appears in the facial, breast, and scrotal areas |
| primary skin lesion | macule/patch, papule/plaque, nodule/tumor, vesicle/bulla, wheal, pustule, cyst |
| secondary skin lesion | erosion, ulcer, scar, fissure, scales, crust, keloid, atrophy, lichenification |
| vascular skin lesions | petechia, ecchymosis, hematoma, cherry angioma, spider angioma, telangiectasis |
| configurations of skin lesions | describing lesions by communicating specific characteristics that can help to identify causes and treatments |
| linear | straight line as in a scratch or streak |
| annular | circular lesions |
| ex-contact dermatitis | resulting from exposure to aero allergins, chemicals, foods, and emotional stress |
| petechia | round red or purple macule, secondary to bool extravasaion, small 1-2mm; associated with bleeding tendencies or emboli to skin |
| ecchymosi | round/irregular macular lesion; larger than petechia; color varies and changes (black, yellow, green hues); secondary to blood extravasation; associated with trauma, bleeding tendencies |
| hematoma | localized collection of blood creating an elevated ecchymosis; associated with trauma |
| cherry angioma | popular and round; red or purple; noted on trunk, extremeties; may blanch with pressure; normal age related skin alterations; usually not clinically significant |
| spider angioma | red, arteriole lesion; central body with radiating branches; noted on face, neck, arms, and trunk; rare below waist; may blanch with pressure; associated with liver disease, pregnancy and vitamin B deficiency |
| telaniectasis (venous star) | shape varies-spiderlike or linear; color bluish or red; doesn't blanch when pressure is applied; noted on legs, anterior chest; secondary to superficial dilation of venous vessels and capillaries; associated with increased venous pressure states (varicosities) |
| edema | abnormal, area will appear swollen, shiny, taut |
| 6 types of edema | dependent, peripheral, pitting, generalized, pulmonary, cerebral |
| pitting edema | evidence of fluid in soft tissues, especially those of dependent body parts like lower extremities; when pressed firmly with finger, tissues that are swollen with extravascular fluid retain in the shape of the depression produced by finger |
| testing for pitting edema | press finger into edematous area for 2-3 seconds and note depth of indenton |
| grading edema 1 + | slight pit |
| grading edema 2+ | deep pit |
| grading edema 3+ | puffy |
| grading edema 4+ | extremely deep pit |
| anterior vertical line | right midclavicular line, midsternal line, left midclavicular line |
| posterior vertical line | left scapular line, vertebral line, right scapular line |
| lateral vertical line | anterior axillary line, midaxillary line, posterior axillary line |
| thoracic cage | constructed of the sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, and cartilage; provides support and protection for organs |
| sternum and clavicle | suprasternal notch is U-shaped identation; sternal angle also known as the angle of Lois is the location of the 2nd pair of ribs and is a reference point for counting ris and intercostal spaces |
| ribs and thoracic vertebrae | ribs constitute main structure of thoracic cage; costal angle is the angle between right and left costal margins that meet at level of xiphoid process and is an important landmark; lower tip of each scapula is at level of 7th or 8th rib when clients arm is at their side |
| vertical reference lines | anterior, posterior, lateral |
| thoracic cavity | mediastinum refers to a cenral area in the thoracic cavity that contains trachea, esophagus, heart, and great vessels; lungs lie on each side of mediastinum |
| lungs | apex of each lung extends slightly above the clavicle; base at the level of diaphragm |
| pleural membranes | parietal pleura line the enxternal surfaces of the lungs |
| pleural space | lies between the 2 pleural layers; 3rd physiologic space for body fluid storage, severe dehydration will reduce volume of pleural fluid, resulting in increased transmission of lung sounds and a possible friction rub |
| the right lung is made of ___ lobes | 3 |
| 2 | the left lung is made of __ lobes |
| trachea | c-shaped rings of hyaline cartilage, help to maintain its shape and prevent its collapse during respirations |
| trachea | bifurcates into right and left main bronchi |
| right bronchi | shorter and more vertical |
| dead space | bronchi and trachea in respiratory system where air is transported but no gas exchange takes place |
| trachea and bronchi are lined with | mucous membranes containing cilia |
| what is the purpose of cilia | sweep dust, foreign bodies and bacteria that have been trapped by mucus toward mouth for removal |
| anterior placement of stethoscope | 10 auscultation sites from clavicle region to below breaths on each side; check from side to side to compare sounds; lift female breast to check 7/8 sites properly |
| posterior placement of stethoscope | 20 auscultation sites from top of back to right below rib cage, check from side to side to compare sounds |
| cyanosis | bluish or gray coloring of the skin due to decreased amounts of hemoglobin in the blood suggesting reduced oxygenation |
| where does cyanosis occur | in the perioral, nail bed, and conjunctival areas (dark skin patients' cyanosis is only severe when the cyanosis is apparent in the skin) |
| where do you observe for cyanosis | face, lips, and chest |
| causes of cyanosis | if client is cold, hypoxic |
| central cyanosis | results from a cardiopulmonary problems such as chronic heart and lung disease |
| where do you observe for central cyanosis | oral mucosa, light skin people have dusky blue color; dark skin people have dark but dull color and should be checked for in the conjunctiva, oral mucosa, nail beds |
| peripheral cyanosis | may be a local problem such as exposure to cold, resulting from vasoconstriction, and anxiety; light skin people have dusky nail beds; dark skin people check conjunctiva, oral mucosa, nail beds |
| inspect nose | inspect external portion of nose for deviations in shape, size, and color; inspect external portion of nasal septum for symmetry and signs of deviation; should separate nares in straight line; assess nares by asking patient to occlude one nare while breathing and do other; gently palpate external nares for tenderness; palpate sinuses |
| nasal flaring | abnormal finding; seen with labored respirations (especially in small children) |
| nasal flaring | indicative of hypoxia (with respect to nose) |
| pursed lip breathing | abnormal finding; may be seen in asthma, emphysema, or CHF as a physiologic response to help slow down respiration and keep alveoli open longer |
| inspect lips for | symmetry, color (more pigmented than facial skin), edema, surface abnormalities (fissures common seen with chapped lips and herpes simplex/cold sores); palpate with gloved hand for moistness, induration (hardness), intactness, and lesions |
| inspect chest | client has evenly colored skin tone without unusual or prominent discoloration |
| barrel chest | abnormal finding; commonly the result of emphysema due to hyperinflation of the lungs |
| abnormal findings face, lips, and chest | ruddy to purple complexion may be seen in clients with COPD or CHF as a result of polycythemia. |
| scoliosis | spinous processes that deviate laterally in the thoracic area |
| barrel chest | ribs appear horizontal at an angle greater than 45 degrees with spinal column are result of an increased ratio between the anteroposterior-transverse diameter |
| tripod position | client leans forward and uses arms to support weight and lift chest to increase breathing capacity; often seen in COPD |
| Unequal chest expansion | can occur with severe atelectasis (collapse or incomplete expansion), pneumonia, chest trauma, or pneumothorax (air in the pleural space) |
| Decreased chest excursion at the base of the lungs is characteristic of | COPD (due to decreased diaphragmatic function) |
| Pectus excavatum | sunken sternum and adjacent cartilages (often referred to as funnel chest); it's a congenital malformation that seldom causes symptoms other than self consciousness; may restrict expansion of lungs and decrease lung capacity |
| pectus carinatum | forward protrusion of the sternum causing the adjacent ribs to slope backward (often referred to as pigeon chest); may restrict expansion of lungs and decrease lung capacity |
| diaphragm | the major muscle used to breathe, evidenced by expansion of lower chest during inspiration |
| signs of acute or chronic airway obstruction or atelectasis | trapezius or shoulder muscles are used to facilitate inspiration |
| neck muscles (sternomastoid, scalene, and trapezius) | used to facilitate inspiration in cases of acute or chronic airway obstruction or atelectasis |
| abdominal muscles and the intercostal muscles | are used to facilitate expiration in COPD |
| Normal breathing pattern | 12-20 breaths per minute and regular; respirations are relaxed, effortless, and quiet |
| tachypnea | greater than 24 breaths a minute and shallow; this may be a normal response to fever, anxiety or exercise; can occur with respiratory insufficiency, alkalosis, pneumonia, or pleurisy |
| bradypnea | less than 10 breaths a minute and regular; may be normal in well conditioned athletes; can occur with medication induced depression of the respiratory center, diabetic coma, and neurologic damage |
| hyperventilation | increased rate and increased depth of breathing; usually occurs with extreme exercise, fear, or anxiety |
| kussmaul's respirations | type of hyperventilation associated with diabetic ketoacidosis |
| causes of hyperventilation | disorders of the CNS, overdose of the drug Salicylate, or severe anxiety |
| hypoventilation | decreased rate, decreased depth, and irregular pattern of breathing; usually associated with overdose of narcotics or anesthetics |
| cheyne-stokes | regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea |
| cheyne-stokes | may result from severe congestive HF, drug overdose, increased intracranial pressure, or renal failure, may be noted in the elderly during sleep |
| biot's respiration | irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea |
| biot's | may be seen with meningitis or severe brain damage |
| tender or painful areas of the chest during palpation | indicate inflamed fibrous connective tissue |
| pain over the intercostal spaces | inflamed pleurae |
| pain over the ribs, especially at the costal chondral junctions | fractured rib |
| tenderness when palpating chest | muscle soreness from exercise or the excessive work of breathing ( as in COPD) |
| increased warmth in chest | local infection |
| tenderness over thoracic muscles | can result from exercising especially in a previously sedentary client |
| resonance | percussion tone elicited over normal lung tissue; percussion elicits flat tones over the scapula |
| hyperresonance | elicited in cases of trapped air such as in emphysema or pneumothorax; dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space such as in lobar pneumonia, pleural effusion, or tumor |
| crepitus (subcutaneous emphysema) | crackling sensation that occurs when air passes through fluid or exudate |
| crepitus | can be palpated if air escapes from lung or other airways into the subcutaneous tissue as occurs after an open thoracic injury, around chest tube, or tracheostomy; may be palpated in areas of extreme congestion or consolidation; mark margins and monitor to note any decrease or increase in the crepitant area |
| fremitus | vibrations of air in the bronchial tubes transmitted to the chest wall |
| fremitus | ask client to say "ninety-nine" as you move your hand to each area, assess all areas for symmetry and identified in upper regions of lungs |
| fremitus | results from consolidation ( which increases it) or bronchial obstruction, air trapping in emphysema, pleural effusion, or pneumothorax (which decreases it) |
| diminished fremitus even with a loud spoken voice may indicate | an obstruction of the tracheobronchial tree |
| diaphragmatic excursion | should be equal bilaterally and measure 3-5cm in adults; level of the diaphragm may be higher on the right because of the position of the liver; in well conditioned clients, excursion can measure up to 7 or 8cm. |
| diaphragmatic excursion | ask client to exhale forcefully and hold the breath; begin at scapular line, percuss the intercostal spaces of the right posterior chest wall; percuss downward until tone changes from resonance to dullness; mark this level and allow client to breathe; next ask client to inhale deeply and hold it, percuss intercostal spaces from mark downward until resonance changes to dullness; mark level and let client breathe; measure distance between the two marks and perform on both sides of the thorax |
| decreased diaphragmatic excursion | descent may be limited by atelectasis of the lower lobes or by emphysema in which diaphragmatic movement and air trapping are minimal; diaphragm remains in low position on inspiration and expiration |
| causes for limited descent | pain or abdominal changes such as extreme ascites, tumors, or pregnancy |
| uneven excursion | may be seen with inflammation from unilateral pneumonia, damage to phrenic nerve or splenomegaly |
| bronchial | high pitch, harsh or hollow quality, loud amplitude; short during inspiration and long during expiration |
| bronchial sounds best heard | over trachea thorax |
| bronchovesicular | moderate pitch, mixed quality, moderate amplitude; same during inspiration and expiration |
| bronchovesicular sounds best heard | over the major bronchi: posterior- between the scapulae; anterior- around the upper sternum in the first and second intercostal spaces |
| vesicular | low pitch, breezy quality, soft amplitude; long on inspiration and short on expiration |
| vesicular sounds best heard | over peripheral lung fields |
| diminished or absent breath sounds | often indicate that little or no air is moving in or out of the lung area being auscultated; may indicate obstruction within lungs as a result of secretions, mucus plug, or foreign object; may also indicate abnormalities of pleural space such as pleural thickening, pleural effusion, or pneumothorax |
| fine crackles | high pitch, short, popping sounds heard during inspiration and not cleared with coughing; sounds are discontinuous and can be simulated by rolling a strand of hair between your fingers near the ear |
| fine crackles | inhaled air suddenly opens the small deflated air passages that are coated and sticky with exudate |
| fine crackles | crackles occur late in inspiration are associated with restrictive diseases such as pneumonia and congestive HF; crackles occur early in inspiration are associated with obstructive disorders such as bronchitis, asthma, or emphysema |
| coarse crackles | low pitch, bubbling, moist sound that may persist from early inspiration to early expiration; also described as softly separating Velcro |
| coarse crackles | inhaled air comes into contact with secretions in the large bronchi and trachea |
| coarse crackles | may indicate pneumonia, pulmonary edema, and pulmonary fibrosis; "velcro rates" of pulmonary fibrosis are heard loouder and closer to stethoscope, usually don't change location, and are more common in clients with long term COPD |
| pleural friction rub | low pitch, dry, grating sound; sound is much like crackles, only more superficial and occurring during both inspiration and expiration |
| pleural friction rub | sound is the result of rubbing of two inflamed pleural surfaces; literally has a rubbing sound, associated with pleuritis |
| wheeze (sibilant) | high pitch, musical sounds heard primarily during expiration but may also be heard on inspiration |
| wheezing (sibilant) | air passes through constricted passages (caused by swelling secretions, and/or tumors) |
| wheezing ( sibilant) | heard with acute asthma or chronic emphysema |
| wheeze (sonorous) | low pitch snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle; these wheezes may clear with coughing |
| wheeze (sonorous) | same as sibilant wheeze; the pitch of the wheeze can't be correlated to the size of the passageway that generates it |
| wheeze (sonorous) | often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea |
| stridor | a harsh honking wheeze with severe broncholaryngospasm, such as occurs with croup |
| white or mucoid sputum | seen with common colds, viral infections, or bronchitis |
| yellow or green sputum | associated with bacterial infections |
| bloody sputum (hemoptysis) | is seen with more serious respiratory conditions |
| rust colored sputum | associated with tuberculosis or pneumococcal pneumonia |
| pink, frothy sputum | indicative of pulmonary edema |
| increased sputum | seen in an increase in exposure to irritants, chronic bronchitis, and pulmonary abscess; clients with excessive, tenacious secretions may need instruction on controlled coughing and measures to reduce viscosity of secretions |
| pack year | # of packs/day x # of years smoking |
| zosteriform | linear lesions clustered along a nerve route |
| discrete | individual and distinct lesions |
| polycyclic | circular lesions that tend to run together |
| confluent | lesions run together |
| macule, Patch | flat, non-palpable skin color change ( sin color may be brown, white, tan, purple red); ex-freckles, flat moles, petechiae, rubella, vitiligo, port wine stains, ecchymosis |
| macule | less than 1 cm, circumscribed border |
| patch | more than 1 cm, may have irregular border |
| papule, plaque | elevate, palpable, solid mass; circumscribed border |
| papule | less than 0.5 cm; ex-elevated nevi, warts, lichen planus |
| plaque | more than 0.5cm ( may be coalesced papules with flat top); ex-psoriasis and actinic keratosis |
| nodule, tumor | elevated, solid, palpable mass; extends deeper into dermis than a papule |
| nodule | 0.5-2 cm, circumscribed; ex-lipoma, squamous cell carcinoma, poorly absorbed injection, dermatofibroma |
| tumor | greater than 1-2 cm; doesn't always have shart borders; ex- larger lipoma and carcinoma |
| vesicle, bulla | circumscribed elevated, palpable mass containing serous fluid |
| vesicle | less than 0.5cm; ex-herpes simplex/zoster, varicella, poison ivy, second degree burn |
| bulla | greater than 0.5cm; ex-pemphigus, contact dermatitis, large burn blisters, poison ivy, bullous impetigo |
| wheal | elevated mass with transient borders; often irregular; size and color vary; ex- urticaria (hives) and insect bites |
| wheal | caused by movement of serous fluid into dermis; doesn't contain free fluid in a cavity (e.g. vesicle) |
| pustule | pus filled vesicle or bulla; ex-acne, impetigo, furuncles, and carbuncles |
| cyst | encapsulated fluid-filled or semisolid mass; located in the subcutaneous tissue or dermis |
| erosion | loss of superficial epidermis; doesn't extend to the dermis; depressed, moist area |
| erosion | ex-rupture vsicles, scratch marks, and aphthous ulcer |
| ulcer | skin loss extending past epidermis; necrotic tissue loss; bleeding and scarring possible |
| ulcer | ex-stasis ulcer of venous insufficiency and pressure ulcer |
| scar (cicatrix) | skin mark left after healing of wound or lesions; represents replacement by connective tissue of the injured tissue |
| young scars | red or purple |
| mature scars | white or glistening |
| scar | ex-healed wound and healed surgical incision |
| fissure | linear crack in the skin; may extend to the dermis |
| fissure | ex-chapped lips or hands and athlete's foot |
| scales | flakes secondary to desquamated, dead epithelium; flakes may adhere to skin surface; color varies (silvery, white); text varies (thick, fine) |
| scales | ex-dandruff, psoriasis, dry skin, and pityiasis rosea |
| crust | dried residue of serum, blood, or pus on skin surface; large adherent crust is a scab |
| crust | ex- residue left after vesicle rupture impetigo, herpes, and eczema |
| keloid | hypertrophied scar tissue; secondary to excessive collagen formation during healing; elevate, irregular, red; greater incidence in african-americans |
| keloid | ex- keloid of ear piercing or surgical incision |
| atrophy | thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; underlying vessels may be visible |
| atrophy | ex-aged skin and arterial insufficiency |
| lichenification | thickening and roughening of the skin; accentuated skin markings; may be secondary to repeated rubbing, irritation, scratching |
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