NUR314.exam.1.

in-depth familiarization with client’s health state

lightly skims on the major areas of current concern, eg. camp form

concentrated on the areas of present concern *episodic

chronology of changes since last seen *follow-up

rapid, direct

-Onset
-Location
-Duration
-Characteristics
-Aggravating/Associated factors
-Relieving factors
-Treatments thus far
-Significance of symptoms to the client

Biophysiological systems approach, often focused on the pathology in a single system

Biopsychosocial approach focused on multiple systems & “the diagnosis & treatment of human responses to actual & potential health problems.

-Addresses 11 main health areas
-Focuses data collection on a person’s response to actual, risk or potential health problems
-Guides the documentation of data
-Supports the choice of nursing diagnoses

(Abe Lincoln) tall, thin stature with long thin fingers, hyper- extensible joins, arms longer than height; early morbidity and mortality occurs as a result of cardiovascular complications

excessive growth hormone during adulthood; causes overgrowth of face, head, hands, and feet but no change in height; also causes overgrowth of organs and metabolic disorders may be present

excessive growth hormone results in overgrowth of entire body; if it occurs during childhood there’s a spurt in weight and height but a delay in sexual development

deficiency of growth hormone, height below the third percentile; delayed puberty, hypothyroidism, baby features, and adrenal insufficiency
• Gigantism- excessive growth hormone results in overgrowth of entire body; if it occurs during childhood there’s a spurt in weight and height but a delay in sexual development

genetic disorder that connects bone to cartilage; normal trunk size, short arms and legs, abdominal protrusion, large head

weight gain and edema with trunk; thin arms and legs; muscle wasting; thin skin with bruising, acne, and purple striae on abdomen

inadequate intake of protein and calories or starved; "starved appearance"; weight loss and SC fat and muscle wasting

protein malnutrition; diets high in calories but lack protein; appear well nourished or even obese

kerotic scaling lesions especially in parts of the body exposed to sun

dry, bumpy skin

profuse sweating

decreased perfusion, vasoconstriction

patchy depigmentation from destruction of melanocytes (patchy milky white spots)

increased amount of unoxygenated hemoglobin (dusky blue)

increased blood flow through engorged arterioles (blushing)

increased RBC (ruddy blue)

decreased blood flow from area

circular; begins in center then spreads to periphery (ring worm)

lesions run together

distinct, individual lesions that are separate (acne, skin tag)

snake-like, coiled spiral, twisted

lesions are clustered together

scratch, line, streak, or stripe

resembles an iris

linear arrangement along a unilateral nerve route

annular lesions grow together

smaller than 1cm, flat, circumscribed, color change (freckle)

smaller than 1cm, elevated, circumscribed (mole)

macules that are larger than 1cm

papules coalesce &form; wider than 1cm, plateu-like disc-shaped lesion

soft or hard, solid, elevated, larger than 1cm; may extend deeper into dermis than papule

hard or soft, larger than a few inches, benign or malignant, deeper into dermis

fluid-filled, slightly irregular shape due to edema, transient, elevated, & superficial (mosquito bite)

wheals coalesce to form extensive reaction (hives)

clear fluid-filled, elevated, up to 1cm (blister)

larger than 1cm, single chambered, superficial in epidermis, thin wall-ruptures easily (friction blister)

fluid-filled; in dermis or subcutaneous; tensely elevated skin, encapsulated

elevated, circumscribed, cavity is filled with pus (acne)

secondary; dried up left over exudate from vesicles/pustules; red-brown, yellow, honey (scab)

secondary; dry or greasy, silvery or white, flakes of skin, from shedding of dead keratin cells (eczema)

secondary; linear crack with abrupt edges, from excess moisture or dry, extends into dermis (at corners of mouth)

secondary; superficial in epidermis, doesnt leave scar, scooped out but shallow depression, no bleeding

secondary; deeper depression extends into dermis, irregular shape, leaves scar, may bleed (pressure sore)

secondary; self inflicted, excessive scratching, superficial, doesnt leave scar, sometimes crusted (bug bite)

secondary; thinning of epidermis, skin level is depressed with loss of tissue (straie)

secondary; looks like moss, many papules in one area, prolonged intense scratching

secondary; hypertrophic scar, elevated by excessive scar tissue, more prominent in blacks, can get larger long after healing occurs, smooth, rubbery, clawlike

bruise or wound whos irregular shape suggest the cause of a weapon or instrument

bruise you can feel, elevated, seen as swelling

(bruise) mechanical injury; skin is intact; red-blue or purple within first 24 hours then progresses

large, flat, patch covering face or scalp; there when born and does not fade; dark red, purplish, bluish; intensifies with crying, exertion, or exposure to hot or cold; mature capillaries

diameter of 2-3cm; raised bright red area with defined edges; does not blanch with pressure; there when born or forms within first few months; gone by age 5-7; no treatment; immature capillaries

redish blue color, spongy and solid, may be present at birth, may enlarge during first 10-15 months

caused by vascular dilation; permanently enlarged and dilated blood vessels; visible on skin surface

fiery red, star-shaped marking; solid circular center; on face neck or chest; may be correlated to pregnancy, chronic liver disease, estrogen therapy, or it may be normal

bluish-purple dilationof venules and capillaries; in a star-shaped, linear, or flaring pattern; with pressure they empty or dissapear; on legs, lips, ears, chest, face

caused by a benign proliferation of blood vessels in the dermis

caused by blood flowing out of breaks in the vessels; RBCs and blood pigments are deposited in the tissues

tiny punctant hemorrages; discrete and round; red, brown, purple; caused by cleeding from superficial capillaries; will not blanch; 1-3mm

in the mouth, paticularly the buccal mucosa, and the conjunctivae

purplish patch resulting from extravasation of blood into skin; >3mm

confluent and extensive patch of petechiae and ecchymosis; >3mm flat; red to purple

red, moist patch with poorly defined edges in diaper area; due to infrequent diaper change; inflammatory disease caused by skin irritation from ammonia, heat, moisture, occlusive diapers

scalding red, moist patches with sharply demarcated borders; usually in genital area; aggravated by urine, feces, heat, and moisture

moist, thin-roofed vesicles with thin erythematous base; most common in infants and children; contagious bacterial infection; rupture to form thick, honey-colored crust

eczema; erythematous papules and vesicles with weeping, oozing, and crusts; forehead, forearm and wrists, back of knees, cheeks, elbows; family history of allergies; sever pruritus

rubeola; red-purple maculopapular blotchy rash that appears 3-4 day of illness; does not blanch; begins first behind ears, then face, neck, trunk, arms, and legs; looks "coppery"

rubella; pink papular rash that begins in face then spreads; paler than measles, presence of lymphadenopathy and absence of koplick spots

small tight vesicles that first appear on trunk then spread to face, arms, and legs; not on soles or palms; intensely puritic; shiny vesicles on erythematous base that becomes pustules then crust

localized inflammatory reaction to something in the environment or an allergy; usually begins with erythema then swelling, wheals, or maculopapular vesicles, scales; intense puritis (poison ivy)

erythematous and symmetrical rash; history of drug ingestion; some produce urticarial rash or vesicles and bullae

(ringworm of body) hyperpigmented in whites; depigmented in blacks; scales that are circular with clear middle; chest, back of arm, abdomen

(ringwork of foot) "Athlete's foot"; first begins with vesticles between toes, sides of feet, and soles then turns hard and scaly; fungal infection; chronically moist, warm feet

cold sore; sensitivity and tingling then tight vesicles appear that turn to pustules then shallow, painful ulcers; common in upper lip and oral mucosa and tounge

fine, round, scaling patches or pink, white, or tan patches that don't tan; neck, trunk, upper arms; superficial fungal infection; responds to oral antifungal medications; most common in healthy young adults

shingles; small, grouped vesicles along cutaneous sensory nerve that turn to pustules then crust; acute appearance; unilateral, does not cross midline; can appear anywhere but common on trunk; common in adults over the age of 50; pain is severe and long lasting- called postherpetic neuralgia; caused by VZV (reactivation of dormant chicken pox)

may have serious cardiac, arthritic, or neurologic sequal; caused by black or brown deer tic; first stage is a bulls eye with a macular or papular rash in 50% of cases which then radiates with central clearing; rash disapears within 4 weeks; most common in axillae, inguina, midriff, or behind knees with regional lymphadenophathy; untreated= fatigue, anorexia, fever, chills, joint or muscle aches

erythematous, scaly patch with silvery scales on top; scalp, outsides of elbows and knees, lower back, and anogenital area

starts with a skin-colored papule with a pearl translucent top with an overlying broken blood vessel; then develops pearly and rounded border with a red ulcer in the center or it looks like an open pore with a central yellowing; most common form of skin cancer; most common in sun-exposed areas of the ears, scalp, face, and shoulders; slow but inexorable growth

erythematous scaly patch with defined margin; 1cm or greater; develops a central ulcer and surrounding erythema; grows rapidly; most common in head and hands, areas exposed to UV radiation; arise from de novo or actinic keratoses

half arise from preexisting nevi; usually brown; can be tan, pink-red, purple, or mixed pigmentation; may have flaking, oozing, scaling texture; trunk and back in men and women; legs on women; palms, soles of feet, and bails in blacks

vascular tumor; most common tumor found in HIV; can occur at any stage; faint pink; can be mistaken for bruise or nevi

scalp ringworm; funal infection; blue green under woods light; rounded patchy hair loss leaving broken off hairs, pustules, and scales on skin; most common in children and farmers; can get from another person, animal, or soil

hair loss along hair line, part, or scattered distribution; baretts, tight braiding, pony tails

patchy, asymmetrical; use of chemo; growing hairs are lost and resting ones are spared

sudden sharply circumscribed balding patching with smooth underlying skin

cradle cap; yellow to white, greasy, thick, scales with mild erythema on scalp and forehead; common in early infancy; resembles eczema lesions but absense of puritis, negative family history of allergy

head lice; intense itching of scapl; occipital area and around ears; combing of wet hair daily is important

in adults can signal a personality disorder; from twisting or plucking hair; hair is never full lost; traumatic, self-induced; irregularly shaped patch with shirt broken hairs

infection of hair follicle; multiple pstules with hair visiable at center; buttocks, arms, legs, face

excessive body hair in females forming a male sexual mattern; upper lip, face, chest, abdomen, arms, legs; caused by endocrinee or metablic dysfunction

red, swollen, hard, tender, pus-filled lesion; localized bacterial infection; back of neck and buttocks=most common; also seen on wrists and ankles; furuncles= infected hair, absess=bacteria infection into skin, usually larger and deeper

intensley puritic contagion caused by scabies mite; cannot stop scratching; usually other family members have it too; form a linear or curved elevated burrow in fingers, wed spaces of hands, and wrists

red, swollen, tender inflammation of the nail folds; acute=bacterial infection; chronic=fungal infection from break in cuticle and performing "wet" work