Nur 300 Exam 1 Content

Vellus vs Terminal hair

Vellus: fine, short

Terminal: Coarse, darker

Sebaceous glands

produce protective oil-sebum

Eccrine glands

Sweat glands: produce an odorless fluid to maintain body temp & produce sweat. located in all skin especially the palms, soles of the feet, axilla region, & forehead

Acne

inflammatory disease of the sebaceous follicles of the skin, marked by comedone, papules, and pustules

Cancer

malignancy of the cells

Eczema

chronic inflammatory skin disorder that causes the skin to become scaly, itchy, inflamed, and irritated

Psoriasis

chronic immune disorder that causes the skin to develop slivery, scaly, plaques

Seborrhea dermatitis

inflammatory skin condition causing flaky, yellow, scale to form on the scalp, ears, and face

albinism

inherited disorder caused by the total or partial absence of an enzyme that produces melanin

Carotenemia

yellowing of the skin due to increased dietary intake of carotene from foods such as carrots, sweet potatoes, pumpkin, corn, etc

Central Cyanosis

bluish discoloration to the skin related to decreased circulating O2, best assessed in the oral mucosa, eyes, lips, and tongue

Erythema

red, pink skin color, may indicate inflammation, fever, or increased blood flow. In CO2 posioning the individual will have bright red cherry face and upper trunk

Level of Consciousness

Alert

Confusion: disoriented, poor memory and commands

Drowsiness: responds stimuli slowly, lethgary

Stupor: responds only briefly to repeated stimuli

Comatose: unresponsive

Glasgow Coma Scale

lower the scale the more the patient is disoriented

Mental Status Exam

AOx4 (person, place, time, events)

Assesing for short term memory

3-word repeat after 5-10mins

Asses long-term memory

ask mothers maiden name or DOB

Evaluate Cognitive Abilities

Mini-Cog

3 un-related words

Clock Face

MMSE

MMSE

mini-mental status exam

object recognition

serial 7s

following written directions

meaning of a phrase

clock face or copying a shape

higher the score the better

CIWA-Ar Scale

evaluates for level of withdrawl

higher the worse —> following CIWA-Ar protocol

Risk Factors

non-modifiable factors: family hx, age, gender

environmental factors: support system, household

metabolic issues: parkinson, cancer, AIDS

Geriatric Depression Scale

over 5 indicates depression

Data Organization

Appearance

Behavior

Cognitive

Thought Processes

Apocrine Glands

produce a body odor when reacting to bacterial decomposition and increases in response to emotional stress: axillary and genital regions

hyperpigmentation

darker skin color

hypopigmentation

lighter skin color

jaundice

yellowing of the skin due to excessive levels of bilirubin in the blood

Pallor

pale skin is seen in anemia, a decrease in circulating red blood cells or flow, or absence of oxygenated blood

peripheral cyanosis

a blue, grey, discoloration of the skin or mucos membranes caused by deoxygenated or reduced hemaglobin in the blood may occur with decreased cardiac output

Vitilligo

autoimmue disorder that causes smooth white patches of skin all over the body

autoimmune diseases

inflammation, redness, hair loss, changes in skin texture

acne vulgaris

a skin condition orginating from sebaccous glands that can cause blemishes, cysts, bumps, pustules

eczema

chronic inflammation of the skin, dry itchy patches

has familial tendancies

hormonal conditions

can change the texture of the skin to dry, oily, or moist

rosacea

inflammatory skin conditions causing redness , sweeling, spider-like blood vessels to develop in the middle of the face

ABCDEs of Melanoma

Asymmetry

Boarder

Color

Diameter

Evolving

Clubbing

early clubbing is 180degrees

clubbing more than 180

normal is 160

Distribution patterns

Nursing Process

Assesment, Diagnosis, Planning, Implementation, Evaluation

Interview Process

1. Intro

2. Working

3. Summarization

Assesment OLDCARTS

Onset, Location, Duration, Character, Alleviating/Aggrevating, Radiation, Timing, Severity

Psychomotor Skils

Inspection

Percussion

Palpitation

Ausculation

Palpitation

Light: press down about 1/4in or 1cm using finger pads

Deep

Percussion

Direct tapping the area with one or two fingertips

Indirect striking finger plexor of one hand on a finger of the other hand pleximeter

Fist (indirect) asses organ tenderness

Evaluates for boarders consistentcy of organs and if there is fluid present in body areas

Acute v. Chronic

Acute: rapid onset, 6 months or less, relieved when cause is treated, surgery/trama/etc

Chronic: gradual onsent, 6 months or more, results of conditions that are difficult to treat, difficult to find lasting relief