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107 Cards in this Set
- Front
- Back
What are the purposes of a health history ?
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to collect subjective & objective data
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What are the purposes of a review of system?
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To evaluate the past and present health state of each body system
To double-check in case significant data were omitted in “present illness section” To evaluate health promotion practices |
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Seven Components of Health History
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1. Biographical Data
2. Reason for Seeking Care 3. Present Health or History of Present Illness 4. Past Health 5. Family History 6. Review of Systems 7. Functional Assessment |
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Biographical Data
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Name
Address and phone number (opt) Age and birth date Birthplace (opt) Sex Marital status Race & Ethnic origin (opt) Occupation—usual and present Source of history |
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Reason for Seeking Care
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symptom and sign
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Present Health or History of Present Illness
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Short statement or Chronological record for ill patient
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Past Health
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Childhood illnesses
Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetric history Immunizations Last examination date Allergies Current medications |
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Family History
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Age and health –or- cause of death of blood relatives
Health of close family members (spouse, children) Family history of various conditions e.g. heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, obesity, mental illness, etc. |
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Functional Assessment
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Measures a person’s SELF-CARE ability in health and in absence of illness and Includes:
ADLs, Independent living, nutrition, social relationships and resources; coping; home environment |
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Functional Assessment Areas
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Self-esteem, self-concept
Activity/exercise Sleep/rest Nutrition/elimination Interpersonal relationships/resources Coping and stress management Personal habits Alcohol Street drugs Environment/hazards Occupational health |
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PQRSTU
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P: Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse?
Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it? R: Region or Radiation. Where is it? Does it spread anywhere? S: Severity Scale. How bad is it (on a scale of 1 to 10)? Is it getting better, worse, staying the same? T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur? U: Understand Patient's Perception of the problem. What do you think it means? |
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eight critical characteristics
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Location
Character or quality (descriptive terms) Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient’s perception |
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What is the purpose of inspection
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Systematic, deliberate critical observations
Concentrated “watching” |
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What is the purpose of palpation
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use of touch to determine texture, size, consistency, & location of body parts.
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What is the purpose of percussion
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tapping the person's skin with short, sharp strokes to assess underlying structures
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What is the purpose of auscultation
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listening to sounds produced by the body
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proper technique of INSPECTION
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begins the moment you first meet the person
always comes first |
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proper technique of PALPATION
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Types- light and deep
Light- detect surface characteristics; accustom patient to being touched (~1/2 inch deep) Deep- best use for abdominal contents (1-2 inches) How Fingertips- Use for fine tactile discrimination Finger-Thumb Opposition- Use for position,shape, consistency of an organ/ mass. Dorsa of hands/fingers - Use for temperature Metacarpophalangeal joints or ulnar side of hand- Use for vibrations |
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proper technique of PERCUSSION
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Non-dominant hand-middle finger placed firmly on area to be percussed; fingers separated
Striker hand: makes a striking force; sharp downward wrist motion; Tip of middle finger strikes joint of middle finger on non-dominant hand |
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proper technique of AUSCULTATION
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listen in certain anatomical areas for presence or absence of sound & for quality of sound heard. Areas assessed: heart, blood vessels, lungs, abdomen
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Hypothermia
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core temperature drops below the required temperature for normal metabolism and body functions which is defined as 35.0 °C (95.0 °F)
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Hyperthermia
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fever
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PULSE DEFICIT
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Apical Rate minus Radial Rate
Obtain by two people simultaneously taking apical rate and radial rate Indicates a weak contraction of the ventricles; occurs with atrial fibrillation, premature beats and heart failure |
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PULSE PRESSURE
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Systolic Pressure minus Diastolic Pressure
reflects Stroke volume: amount of blood the heart pumps with each beat ( ~70 ml per beat in adult) |
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Apnea
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suspension of external breathing
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Bradypnea
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abnormally slow breathing rate.
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Eupnea
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normal, good, unlabored ventilation
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Cheyne-stokes
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The pattern of breathing with gradual increase in depth and sometimes in rate to a maximum, followed by a decrease resulting in apnea
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Tachypnea
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rapid breathing
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Cardiac output (CO=SV x R)
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equals the volume of blood in each systole (called the stroke volume) times the number of beats per minute (rate)
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What information is obtained in physical appearance?
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Age
Gender Level of conscious-ness Skin color Facial features |
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What information is obtained in Body structure
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Stature
Nutrition Symmetry Posture Position Body build, contour Obvious physical deformities |
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What information is obtained in Mobility?
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Gait
Range of motion |
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What information is obtained in Behavior?
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Facial expression
Mood and affect Speech Dress Personal hygiene |
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various routes of temperature measurement
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Oral/Electronic thermometer- swift, accurate and convenient
Electronic thermometer- swift, accurate, unbreakable, disposable probe covers Axillary- safe and accurate for infants and young children when environment is controlled Rectal- used only when other routes are not practical. use when cannot close mouth because of O2 or breathing tubes; eg comatose, confused, in shock Tympanic membrane thermometer (TMT)- senses infrared emissions of the tympanic membrane; Used in unconscious or unwilling to cooperate |
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What are the four qualities considered when one assesses the pulse?
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RATE-Normal rate for adult age group 60-100
Bradycardia- < 60 bpm; Tachycardia- >100 bpm RHYTHM- normally, an even tempo regular or irregular FORCE: 3+ full, 2+ normal; 1+ weak & thready, 0- absent ELASTICITY- springy, straight, resilient |
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What is the appropriate procedure for assessing normal respirations?
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assess while person is unaware;
count for 30 seconds unless suspect abnormality |
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what is blood pressure
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the pressure exerted by circulating blood upon the walls of blood vessels
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what is Systolic pressure
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maximum pressure felt on the artery during LV contraction or systole
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diastolic pressure is
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elastic recoil or resting pressure that blood exerts between each contraction
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pulse pressure is
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the pressure of the pulse; the difference between the systolic and diastolic pressures.
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pulse deficit
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difference between the heart rate and the pulse rate in atrial fibrillation.
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patient factors that affect blood pressure:
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Take BP when person is anxious, angry, just exercised
Faculty arm position, above or below level of heart Inaccurate cuff size ( most common error) Cuff wrapped too loose or uneven or bladder outside Falsely high systolic readings when Deflating cuff too slowly Legs not flat on floor: crossed Falsely high diastolic readings when Person supports their own arm Halting during descent and re-inflating to recheck systolic |
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What is normal BMI range
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18.5-24.9
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normal value for Temperature
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Normal Oral 98.6 F (37 C) with range of 94.6 (35.8) to 99.1 (37.3)
Rectal range : 99 .3 F (37.4 C) to 99.6 F (38.40 C) |
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normal value for Pulse
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Normal rate for adult age group 60-100
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normal value for Blood Pressure
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Normal BP: < or = 120/ < or = 80
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normal value for Respirations
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Normal rate for age group: Adult 10-20/min
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How do you obtain Temperature
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thermometer
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How do you obtain Pulse
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use pads of first 3 fingers,
at flexor aspect of wrist laterally along radial bone; press until you feel the strongest pulsation |
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How do you obtain blood pressure
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Use Sphygmomanometer and stethoscope
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How do you obtain respiration
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assess while person is unaware;
count for 30 seconds unless suspect abnormality |
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Annular
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circular
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Confluent
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(run together)
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Discrete
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Discrete (distinct)
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Grouped
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Grouped (clusters)
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gyrate
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Gyrate (twisted; coiled)
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target or iris
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Target or iris (concentric rings)
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linear
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Linear (scratch; streak)
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polycyclic
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Polycyclic (annular lesions run together)
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Zosteriform
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Zosteriform (linear, along nerve route)
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Macule
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color change; flat, < 1 cm.
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Papule
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color change ;elevated; < 1 cm.
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Nodule –
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solid, elevated; into dermis; > 1 cm
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Tumor –
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a nodule that is > few cms
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Wheal –
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superficial, red, raised, edema within
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Urticaria -
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wheals that coalesce (hives)
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Cyst –
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encapsulated fluid-filled; elevated
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Vesicle-
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elevated w/ free-flowing fluid, < 1 cm; eg.”blister”
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Pustule –
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turbid (pus) fluid; elevated, circumscribed; eg. “acne”
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Epidermis made of
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Major ingredient: tough, fibrous protein (keratin)
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Dermis
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Major ingredient : Fibrous Connective tissue (collagen)
Also, resilient elastic tissue (stretch) Contains: nerves, sensory receptors, blood vessels, and lymphatics |
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Subcutaneous Layer
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Major ingredient :Adipose tissue
Stores fat cells for energy, provides insulation for temperature control, aids in protection (soft cushioning) |
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What happens to each of the 3 layers of skin as we age?
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1. Dry wrinkled skin from
turgor and sebaceous gland activity) 2. Fragile epidermis at risk for tears or injury from epidermis thickness 3. More susceptible to dry skin and sensation of pain/touch/temperature from perfusion of the dermis 4. Subcutaneous skin layer thins so risk of hypothermia and risk of pressure ulcers 5. Number of active epidermis melanocytes so susceptability to sun exposure 6.Hyperplasia of melanocytes in sun exposed areas so hyperpigmentation (liver spots= lentigines and hypopigmentation (age spots) …especially on hands |
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What is the preferred precise way to determine lesion size?
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cm
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5. What are four types of abnormal color changes to the skin
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Pallor
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Jaundice
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Yellow color=> rising amounts of bilirubin in blood
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Cyanosis
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Bluish mottled color=> decreased perfusion with oxygenated blood
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Erythema
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Intense redness from excess blood (hyperemia) in dilated superficial capillaries;
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Pallor
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loss of the red-pink tones from oxygenated hemoglobin; epidermis takes on color of collagen layer (dermis)
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Where on the body would you pallor color changes???...in light skinned? In dark skinned
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light skin-> pale, white
brown-skin-> yellow-brown black skin-> ashen gray Generalized pallor seen in: mucous membranes, lips, nail beds, Pallor of anemia seen in: palpebral conjunctiva and nail beds |
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Where on the body would you Erythema color changes???...in light skinned? In dark skinned
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Light skin- red, bright pink
Dark skin- purplish tinge; best to palpate for warmth |
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Where on the body would you cyanosis color changes???...in light skinned? In dark skinned
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Light skin- dusky blue
Dark skin- dark but dull; best to check conjunctiva, oral mucosa, nail bed |
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Where on the body would you Jaundice
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Yellow color=> rising amounts of bilirubin in blood
Light skin=>sclera, hard palate, mucous membrane, then over skin Dark skin=> junction of hard & soft palate in mouth; palms |
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What is skin turgor and how is it assessed and for what reason?
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Turgor (skin return to place promptly)
Normal: No ”tenting” (stands by itself) Reflects elasticity of skin. Poor turgor may = severe dehydration or weight loss |
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What does the ABCDE rule stand for and what does it assess?
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Teach skin self-examination
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basal cell carcinoma
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most common type skin cancer. It appears as a raised soft lump or a red patch on sun-exposed areas of the body.
Found most often on the head or neck, and somewhat less often on the arms and legs. A slow-growing cancer that only rarely spreads to other areas of the body. But if left untreated, it can extend deep below the skin and cause local damage and scarring. |
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malignant melanoma lesions
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3 percent of all skin cancers, but 75 percent of all skin cancer deaths.
Malignant melanoma develops on sun-exposed areas of the skin, as well as inside the eye, in the mouth, and on the palms of the hands and soles of the feet — and it usually starts in a skin mole. Malignant melanoma often occurs at a younger age than other skin cancers; It is the most common type of cancer in people aged 20 to 29. [CDC 2007] |
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What are normal finding when assessing nails, nail beds of fingers or toes, and circulation? How is it done?
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Shape and contour
Profile sign= ankle of nail base (normal is 1600 or less) Consistency smooth, regular; not brittle or splitting Color - even; pink nail bed underneath capillary refill: normal= less than 3 seconds inspect toenails; separate toes and note smooth skin in between |
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Describe the rash that occurs with shingles. What is part of the treatment for this as described in the PPT?
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caused by the reactivation of the chickenpox virus, varicella zoster, which can lie dormant for years in the nerve tissue of a person who has had chickenpox.
Once the virus reawakens, it spreads up the nerve fibers to the skin and produces the telltale rash of shingles. Shingles appear as a blistering rash that runs along one half of the body (usually, thorax area) in a belt-like fashion. |
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What examinations are performed on the neck, head and how do you do them?
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1. Inspect and palpate the skull
General size and contour Note any deformities, lumps, tenderness Palpate temporal artery, temporomandibular joint 2. Inspect the face Facial expression Symmetry of movement (cranial nerve VII) Any involuntary movements, edema, lesions 3. Inspect and palpate the neck Active ROM Enlargement of salivary glands, lymph nodes, thyroid gland Position of the trachea 4. Auscultate the thyroid For bruit (if enlarged) |
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What happens to vision as one ages?
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Visual fields narrow and depth perception is distorted (especially climbing/descending stairs)
Pupils are smaller, reducing night vision Lens yellow and become opaque, resulting in distortion of green, blue and violet tones; and increased sensitivity to glare Production of tears decrease so eyes feel dry or burn |
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What are the 3 most prevalent problems that plague older patients?
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Cataract, Glaucoma, Macular degeneration
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What are the three visual reflexes and how do your perform them?
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1. Pupillary light reflex
normal constriction of pupils when bright light shines on retina; no conscious control of it. A. Direct light reflex- when bright light exposed to one eye B. Consensual light reflex-simultaneous constriction of other pupil 2. Fixation a reflex directing eye towards an object attracting that person’s attention; Impaired by drugs, alcohol, fatigue 3. Accommodation convergence of the axes of the eyeballs with constriction of the pupils: adapts eyes for near vision |
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cornea
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covers iris and pupil
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sclera
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fibrous protective white covering
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conjunctiva
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thin mucous membrane; transparent protective covering of eyeball and mucous membrane
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how you would assess for:
accommodation |
Have person focus on distant object; should see pupils dilate. Then, have person shift gaze to near object –your finger held ~3 inches from nose;
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how you would assess for:
PERRLA |
How (3 steps):
nspect both for round and equal Pupillary light reflex HOW: Advance light in from each side forward from ear Accommodation HOW: Have person focus on distant object; should see pupils dilate. Then, have person shift gaze to near object –your finger held ~3 inches from nose; |
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how you would assess for:
confrontation |
Cover patient’s eye & opposite eye of examiner
2 ft away using pencil or finger Slowly advance it in from periphery- Ask person to say “now” when sees it |
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confrontation
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Gross measure of peripheral vision - CN II
Compare patient’s peripheral vision to examiner (assuming it’s normal |
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PERRLA
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P, Pupils; E, Equal; R, Round; R, React to light; A, Accommodate
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Corneal light reflex (Hirschberg test)
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Assesses parallel alignment of eye axes by shining light towards person’s eye.
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vertigo
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room spinning; true twirling motion
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18. What happens to hearing as one ages?
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Cilia lining the ear canal becomes course and thick so sounds waves traveling toward eardrum are impeded
Causes cerumen to accumulate and appocrine gland atrophy makes cerumen drier A life history of frequent infections results in eardrum scarring |
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cn I
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nose
olfatory |
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cn 2
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eyes peripheral vision
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