N310.01 Exam 2 Lecture Concepts

SFSU SP 2025

Cachexia

weakness, body appears to be wasting away d/t chronic diseases (cancer, aids, end of life, long term illness)

• sunken cheekbones

• visible ribs

• weight loss

Failure to Thrive

weight loss, loss of appetite, pt is lethargic, can’t get enough nutrition

Anemia

iron deficient, lack or RBC, can cause:

• cheilosis

• pernicious anemia

• iron deficiency (due to lack of nutrition)

cheilosis

cuts in around the mouth or face caused by iron or vitamin B12 deficiency

pernicious anemia

anemia that occurs because the body cannot absorb enough vitamin B12, can be d/t:

• nutritional deficits

• autoimmune disorder where immune system attacks cells in the stomach lining that produce intrinsic factor needed to absorb vitamin B12 from food

Kwashiorkor

condition in children that results from mainly protein deficiency

• abdomen is not proportional to the body due to decreased albumin causing fluid accumulation

• protuberant belly

• itchy rash

• poor wound healing

Marasmus

condition in children that results from inadequate intake of any type of nutrition

• skin and bone appearance

• decrease in subcutaneous fat

pressure ulcer/injury/bedsore

areas of skin breakdown or deep tissue injury, staged I-IV or unstageable

common pressure ulcer areas

• back of the heels

• tips of the toes

• coccyx

• behind ears

• shoulder blades

• nose bridge

• any area of bony prominences

deep tissue injury

purple or maroon localized area of discolored intact skin OR blood filled blister due to damage of underlying soft tissue from pressure and/or shear

• area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue

stage I pressure injury

intact skin with non-blanchable redness of a localized area

• usually over a bony prominence

• may be painful, firm, soft, warmer or cooler compared to adjacent skin

• skin stays red after removing pressure for 30 min

• DO NOT massage the affected skin

stage II pressure injury

partial thickness loss of skin w/ exposed dermis

• shallow, open ulcer w/ red-pink wound bed

• no slough

• depth cannot be measured

• OR may look like an intact or ruptured serum filled-blister

• epidermis and dermis layer affected

stage III pressure injury

full thickness tissue loss (epidermis, dermis, subcutaneous affected)

• adipose tissue may be visible

• granulation tissue, slough or eschar may be present

• epibole: rolled wound edges present

• depth can be measured

stage IV pressure injury

full thickness tissue loss

• exposed bone, tendon or muscle

• slough, eschar and epibole present

• can include undermining or tunneling

• depth is measureable

unstageable pressure injury

full thickness tissue loss where the actual depth is unknown due to the wound being completely obscured by slough or eschar

• yellow, tan, gray, green, brown

• eschar can appear black

• if slough/eschar is removed, it would reveal a stage III or IV

• DO NOT remove stable eschar from the wound site

Braden Scale

predicts risk for pressure ulcers using 6 risk factors, each graded from 1-4 (4 being the least risky)

risk factors:

• sensory perception

• moisture

• activity

• mobility

• nutrition

• friction and shear

Braden Scale Scoring

• highest possible score: 23

• if score < 9 → severe risk of skin breakdown or impaired skin integrity

pressure ulcer intervention

• turn/reposition pt q2h

• change bedding often

• frequent peri care assessment

• frequent skin care (barrier cream)

• use of pillows/padding

• using draw sheets to move the pt

• proper nutrition (diet for healthy skin, collagen, vit C)

• ROM exercises

• air fluidized beds

lesions

any area of skin that differs from the surrounding skin in appearance or texture, such as a bump, sore, or patch

• can be primary, secondary, vascular

primary lesions

lesions that arise from healthy skin tissue, part of skin, born with it.

secondary lesions

results from a change in a primary skin lesion OR as a result of an injury

vascular lesions

associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic disease, among other problems

• anything that fills back in with blood

examples of primary lesions

• macule

• patch

• papule

• plaque

• nodule

• tumor

• vesicle

• bulla

• wheal

• pustule

• cyst

examples of secondary lesions

• erosion

• ulcer

• scar

• fissure

examples of vascular lesions

• petechiae

• ecchymosis

• hematoma

• cherry angioma

• spider angioma

• telangiectasis (venous star)

ecchymosis

bruising in a large area (> 1 cm), vascular lesion

• blood seeps into dermal layer due to deep tissue injury

• yellow, black, blue, green, purple

Identifying cancerous skin lesions

• A: Asymmetrical

• B: irregular Borders

• C: Color variations

• D: Diameter >1/4 in

• E: Evolution (lesion changes over time, or Elevated)

• F: Firm

• G: Growing

skin turgor assessment

used to assess for dehydration

• test on the chest wall

• expected: instant recoli

• unexpected: tenting → severe dehydration

skin pallor

loss of color, tones vary from pale to ashen w/ no tinge of pink

seen in:

• arterial insufficiency

• decreased blood supply

• anemia

cyanotic skin

• white skin may appear blue-tinged, especially around the mouth, nail bed, and conjunctival areas

• Dark skin may appear blue, dull, and lifeless in the same areas.

• associated w/ oxygen deficiency

• central cyanosis → cardiopulmonary issue

• peripheral cyanosis → vasoconstriction issue

erythema

skin redness and warmth

seen in:

• inflammation

• allergic reactions

• trauma

jaundice of the skin

yellow skin tones (pale to pumpkin) particularly of the sclera, oral mucosa, palms, and soles

• associated w/ hepatic dysfunction

vitiligo

hyperpigmentation OR lack of pigmentation of the skin

congenital dermal melanocytosis (CDM)

benign, flat, bluish-gray birthmarks that typically appear on the lower back or buttocks of infants

• born w/ them

• will disappear in a few years

• formerly known as “Mongolian spots”

• d/t increased number of melanocytes

millia

small, white or yellowish bumps that form under the skin due to trapped keratin, harmless

striae

stretch marks, can be d/t:

• pregnancy

• obesity

• stretched out skin from a liver condition (fluid accummulation)

alopecia

hair loss that may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy, systemic conditions (hypothyroidism), malabsorption conditions

• can be patchy or generalized hair loss

• propecia medication (grows hair)

pediculosis

lice infestation

keloid scarring

secondary lesion, excessive tissue growth not caused by infection

bulla

Circumscribed elevated, palpable mass containing serous fluid > 1 cm

• blisters from new shoes

• remove pressure and have the fluid be absorbed

• reversible skin change

macule

small, flat, nonpalpable skin color change, < 1 cm with circumscribed border

• may be brown, white, tan, purple, red

pusutle

vesicle containing pus (inflammatory cells)

• ex. acne

crust

dried serum or exudate on skin

• seen w/ chicken pox

fissure

Linear cracks in the skin that may extend to the dermis and may be painful

• chapped lips

scar

skin mark left after healing of wound or lesion that represents replacement by connective tissue

• young scars → red or purple

• mature scars → white or glistening

• aka cicatrix

petechiae

round red or purple macules that are 1 to 2 mm in size.

• secondary to blood extravasation

• associated with bleeding tendencies or emboli to skin.

• looks like little pinpoint spots

purpura

combination of petechiae and ecchymosis, red, purple or brown blood spots on the skin

• d/t small blood vessels leaking under the skin.

shingles

usually presents as clusters of red vesicles on different parts of the body, the lesions are first tingly, then painful, then itchy

• common on the face, armpit and flank area

• contact precaution

• the varicella virus lays dormant on the dorsal ganglion in the body and flares up from time to time d/t stress or other things

• Rx: antiviral medication

stiff neck

nuchal rigidity → possible meningitis

facial features associated w/ parkinson’s disease

• mask-like face, blank expression

• flat facial affect

• drooling

• other symptoms include: shuffling gait, rigid muscles, and diminished reflexes pill-rolling, tremors

facial features associated w/ cushing syndrome

• round “moon” face

• reddened cheeks

• increased facial hair

• other symptoms: thin skin, thin arms + legs, thinning hair, fat pad below the back of the neck, extra body fat around abdomen

• disease d/t: excessive cortisol hormone OR drug induced (steroids, prednisone)

facial features associated w/ systemic “Lupus” erythematosus

• cheek (malar) or butterfly rash

• autoimmune disorder, body attacks healthy tissues and organs, pt is fatigued, weak, can affect kidney bc spleen doesn’t work

facial features associated w/ Bells Palsy

facial nerve (trigeminal) lesion

• One-sided facial paralysis

• usually begins suddenly and peaks within 48 hours

• Symptoms may include twitching, weakness, paralysis, drooping eyelid or corner of the mouth, drooling, dry eye, dry mouth, decreased ability to taste, eye tearing, and facial distortion.

facial features associated w/ stroke

usually affects only the lower part of the face, does not affect the entire facial nerve

corneal reflex “blink test”

using a wisp of cotton to touch cornea to see if pt will blink

• tests the function of CN V (trigeminal nerve)

• usually done for people in a coma

ptosis or blepharoptosis

drooping of the upper eyelid

• could be d/t lack of skin elasticity, oculomotor nerve damage, grave’s disease, congenital

ectropion

lower eyelid folds out

• d/t lack of elasticity

• exposure and drying of conjunctiva

entropion

lower eyelid folds inward

• may injure cornea or conjunctiva bc eyelashes brush against it

exophthalmos

protruding eyeballs w/ retracted lid margins

• associated w/ Grave’s disease (hyperthyroidism)

• autoimmune antibodies attack muscles and soft tissues around the eyeballs

glaucoma

group of eye diseases that damage the optic nerve, often caused by abnormally high pressure (IOP) within the eye, can lead to gradual vision loss (peripheral vision loss)

• open angle → most common

• angle-closure → medical emergency

• Rx: beta blocker eyedrops to reduce pressure

open-angle glaucoma

eye structures appear normal but fluid in the eye (aqueous humor) does not flow properly through the drain of the eye (trabecular meshwork)

• most common, associated w/ diabetes

• could be d/t a blockage or a production of extra aqueous humor

angle-closure glaucoma

poor eye drainage d/t the angle b/t the iris and the cornea being too narrow and is physically blocked by the iris. this leads to a sudden buildup of pressure in the eye

• more common in asia

cataract

opacity of the lens from aging + protein buildup in the lens

• leading cause of blindness

• initial blurring to complete opaqueness

• treatable via surgery (lens replacement)

age related macular degeneration

central vision loss

• central vision may appear distorted, gray, blurry or have blank spots

retinal detachment

retina → light sensitive tissues that line the back of the eye

• detachment is a medical emergency that can lead to blindness

• appears like a curtain closing in with floaters or black spots

• could be d/t a physical “jolt” from movement or come on suddenly

expected tympanic membrane appearance

• should be clear and pearly colored

• right ear: cone of light @ 4-5 pm location

• left ear: cone of light @ 7 pm location

weber test

placing a tuning fork on the skull/forehead to see which side the sound is louder on

• for a pt that has known diminished hearing in one ear

• distinguishes if the hearing loss is conductive or sensorineural

weber test: conductive hearing loss

sound lateralizes to the bad/affected ear

• good/unaffected ear is distracted by background noise and conducted air

• poor ear has trouble hearing those so, the poor ear receives most of the sound conducted by bone vibration.

weber test: sensorineural hearing loss

sound lateralizes to the good/unaffected ear

• bad/affected ear has limited perception of the sound due to nerve damage

• sound seems louder in the unaffected ear

rinne test

placing a tuning fork on the mastoid process, when sound is no longer heard, move the prongs of the fork in front of the external auditory canal.

• compares the length of sound for air and bone conduction

• normal result: air conduction > bone conduction

rinne test: conductive hearing loss

• air conduction ≤ bone conduction

rinne test: sensorineural hearing loss

• air conduction > bone conduction but the time interval for both is shorter than in a normal pt

myringotomy

a tube is placed within the eardrum to prevent fluid buildup from an ear infection

• tube will fall out in 6-12 mo or be removed in 2-3 yrs

perforated tympanic membrane

a tear or hole in the eardrum

• can heal, but with scarring

• d/t rupture, trauma, infection, severe blow, foreign object, cotton swab

epistaxis

nose bleed

interventions for epistaxis (smaller bleeds)

• sit up, slightly lean forward and tilt head forward

• pinch tip of nose for 15-20 min

• if bleeding continues → topical nasal sprays

interventions for epistaxis (recurrent episodes, non-stop bleeding)

• nasal packing: insert gauze into nasal cavity

goiter

enlarged thyroid gland

gingival hyperplasia

enlarged, reddened gums

• some drugs (Dilantin) can cause this, reversible

• seen in pregnancy, puberty, leukemia

peau d’orange

skin on the breast represents orange peel

• associated w/ breast cancer

• blocked lymphatic drainage can also cause edema

tail of spence

upper outer quadrant of the breast, next to axillae

• where cancers are commonly found

sentinel node

the first lymph nodes where cancer cells are likely to spread from a tumor, these nodes lead to the entire body

fine needle aspiration biopsy

a biopsy of breast tissue to check for the presence of cancer in a sentinel node.

• if cancer cells present → surgically remove sentinel node

colostrum

first form of breastmilk produced after giving birth

• nutrient dense and high in antibodies

lymph from the right upper quadrant of the body drains to ?

the right subclavian vein

lymph from the lower extremities and left side of the body drains to ?

the left subclavian vein

heaves or lifts

abnormal pulsations of the chest wall

• indicates forceful heart contractions, palpable

• could be d/t enlarged ventricle

thrills

abnormal rumbling-feeling, “cat purring”

• d/t turbulent flow, or narrowing of an artery

measuring jugular vein distention

• pt is in supine + HOB @ 30 or 45 degrees

• pt’s head is turned away from site of observation

• measure height w/ a ruler on the angle of Louis

jugular vein distention @ 30 degrees

height is > 3 cm

jugular vein distention @ 45 degrees

height is > 4.5 cm

what does jugular vein distention mean?

right sided heart failure, the right side of the heart is backed up bc of too much venous return

S1 split

when the S1 heart sound is heard as two distinct sounds instead of one

• d/t the mitral valve closing first before the tricuspid valve

• the mitral valve could close first due to increased pressure on left side of heart and bc of the route configuration of myocardial depolarization

S2 split

when the S2 heart sound is heard as two distinct sounds instead of one

• d/t aortic valve closing first bc of increased pressure on left side of heart and route of myocardial depolarization

• split is heard best on inspiration (pulmonic valve closes last bc of changes in intrathoracic pressure)

murmurs

d/t turbulent blood flow in the heart or through the valves

• associated w/ mitral + aortic valves

• graded on a scale of I-VI (how loud the murmur is)

vegetative valves

heart valves are like wilted lettuce, valves don’t close well

• d/t endocarditis

• cause murmurs

bruits

turbulent flow of the blood vessels

• d/t rapid flow or flow through a narrowed vessel

S3 and S4

vibration sounds that sound like an extra heart sound

• d/t blood rushing into the heart, rapid ventricular filling

• not d/t valve closure

S3

• occurs during early diastole (ventricular filling) right after S2

• blood is sloshing in to an enlarged ventricle

• best heard when pt is left side-lying recumbent position

• physiological in kids

• “ken-tuck’-y”

S4

• occurs w/ end diastolic filling, when atria is contracting just before S1

• caused by ventricle muscle stiffness or resistance

• a “thick wall” plat sound

• “ten’-nes-see”