Studied by 9 people
(also includes lab PowerPoint notes)
what is the term for itchiness?
pruritus
ABCDEF stands for?
If any lesions are present, note the following:
Asymmetry
Border irregularity
Color variations
Diameter greater than 6 mm
Elevation or evolution
Funny looking; different from others
what is the term for hives?
urticaria
what is the term for hair loss?
alopecia
the mediastinum is?
the middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels
the right and left plueral cavities contain what?
Lungs
(make sure to note lung borders at apex, base, lateral and posterior positions)
the parietal pleura lines what?
chest cavity
the visceral pleura encloses what?
the lung
pleural cavity has __________ pressure
negative
Trachea and bronchi transport what?
gas
bronchial tree has what?
alveoli
First seven ribs attach to what?
sternum (by costal cartilages)
Ribs 8, 9, and 10 attach to what?
costal cartilage above
Ribs 11 and 12 are what?
floating (with free palpable tips)
Costochondral junctions are what?
points at which ribs join their cartilages (they are not palpable)
Suprasternal notch:
U shaped depression just above sternum between clavicles
How do you find vertebra prominens?
Flex your head and feel for most prominent bony spur protruding at base of neck
How do you find spinous processes?
Count down knobs on vertebrae, which stack together to form spinal column
Scapulae are located symmetrically in each ____________
hemothorax
How do you find the twelfth rib?
Palpate midway between spine and a person’s side to identify its free tip
When you lift up a person’s arm 90 degrees, you divide the lateral chest by what three lines?
Anterior axillary, midaxillary, and posterior axillary
The right lung is shorter than the left because of what?
underlying liver
The left lung is narrower than the right because of what?
the heart bulges to left
How many lobes does the right lung have?
3
How many lobes does the left lung have?
2
Asthma key facts:
~most common chronic disease in childhood
~highest burden seen in those living at or below the federal poverty level
Common concern questions to ask related to the lungs:
Have you noticed any shortness of breath or fatigue with your daily activities?
Tell me about your usual amount of physical activity.
How is your energy level? Do you tire more easily? How does your illness affect you at home and at work?
Do you have any chest pain with breathing?
Do you have any chest pain after a bout of coughing or after a fall?
Does the sputum have an odor? How much are you producing? What color is it?
Any exposure to chemicals, vapors, asbestos, or allergens?
Any occupational or recreational concerns?
Do you smoke tobacco?
Are you exposed to secondhand smoke?
Have you recently traveled out of the country?
Do you use any other drugs or alcohol?
Anteroposterior (AP) diameter is ______ than transverse diameter
less
You check the _____ and ______ of respiration
Rate, depth
(you also look for accessory muscle use and retraction)
Where do you look for pallor (paleness) and cyanosis?
in the skin, lips, nail beds, extremities
Increased fremitus =
consolidation
When would you have a patient repeat the phrase “ninety-nine?”
when assessing for tactile (vocal) fremitus
We percuss in ___________ ________, not on bone
intercostal spaces
Resonance is what?
a low-pitched, clear, hollow sound
When auscultating a patients lungs you?
~instruct client to breathe through mouth
~start at apices, move to bases
~one full respiration at each location
~compare bilaterally
Vesicular:
heard over lung fields except upper sternum and between scapulae, quiet and low pitched, “breezy”
Bronchial:
heard over trachea, louder and higher pitched, hollow, tubular
Bronchovesicular:
heard over main bronchi, medium pitch, “breezy and tubular”
When auscultating a females chest you?
Displace the breast and listen directly over the chest wall
Fine Crackles (Rales)
Usually inspiratory, discontinuous, moist sounding
High-pitched, crackling, popping sounds
(pneumonia, heart failure, COPD, bronchitis)
Coarse Crackles
Loud, low-pitched, bubbling, gurgling
(pulmonary edema, pulmonary fibrosis)
Atelectatic
Short, popping, crackling like fine crackles but dissipate after deep breaths
Pleural friction rub
Superficial sound
Coarse, low-pitched, grating quality
(pleuritis)
Sibilant Wheeze
Continuous, musical sounds from air passing through narrowed passage in small airways
High-pitched, squeaking
(asthma, chronic emphysema)
Sonorous Wheeze
Continuous, snoring sound from narrowed large airways
Low-pitched, single note, moaning sound
(bronchitis, obstruction)
Stridor
Continuous, crowing, partial obstruction of trachea
(croup, epiglottitis, foreign body)
Increased tactile fremitus occurs with?
conditions that increase the density of lung tissue, thereby making a better-conducting medium for vibrations (e.g., compression or consolidation [pneumonia])
There must be a patent bronchus, and consolidation must extend to the lung surface for increased fremitus to be apparent
Aging changes with the lungs:
Decreased vital capacity
Less surface area is available for gas exchange
(this increases the older person's risk for dyspnea with exertion beyond his or her usual workload)
When auscultating an older patient, make sure to?
Take care that this person does not hyperventilate and become dizzy.
Allow brief rest periods or quiet breathing.
(if the person does feel faint, holding the breath for a few seconds restores equilibrium)
What is nutrition?
Balance between nutrient intake and nutrient requirement
Optimal nutritional status is achieved when?
sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands due to growth, pregnancy, or illness
Under nutritional status occurs when?
nutritional reserves are depleted or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands
Over nutritional status is caused by?
consumption of nutrients, especially calories, sodium, and fat, in excess of body needs
During adulthood, growth and nutrient needs ___________
stabilize
What lifestyle factors can lead to the development of disease?
cigarette smoking, stress, lack of exercise, excessive alcohol intake, and diets high in saturated fat, cholesterol, salt, and sugar and low in fiber
(adult years, therefore, are an important time for education to preserve health and to prevent or delay the onset of chronic disease)
Adult emergence of Metabolic syndrome is a concern that can lead to?
increased cardiac risk
Being overweight during childhood and adolescence is associated with ___________ risk for becoming overweight during adulthood
increased
Common concern questions to ask relating to nutrition:
What are your eating patterns?
What is your usual weight? Have you had recent weight change? What was the reason for the loss or gain?
Any changes in appetite, taste, smell, chewing, or swallowing?
Are you able to feed yourself? Are you able to go to the store?
Any recent vomiting, diarrhea, or constipation?
Any food allergies or intolerances?
What are your exercise patterns?
Number of meals/snacks per day?
Kind and amount of food eaten?
Fad, special, or alternative diets?
Where is food eaten?
Food preferences and dislikes?
Religious or cultural restrictions?
Able to feed self?
When assessing nutritional status, you should include?
weight (BMI) and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data.
Nutrition screening tools:
Admission Nutrition Screening Tool (validated for use by nurses in hospital settings)
Nutrition Screening Initiative form (designed and validated in outpatient, geriatric population)
Individuals identified at nutritional risk during screening should undergo a comprehensive nutritional assessment, which includes the following:
~dietary history and clinical information
~physical examination for clinical signs and anthropometric measures
~laboratory tests
Obese, cachectic (fat and muscle wasting), or edematous (malnutrition caused by a lack of protein in the diet), can provide clues to?
overall nutritional status
Where would you observe for late manifestations of malnutrition?
in the skin, hair, mouth, lips, and eyes
(areas of rapid turnover of epithelial tissue)
Laboratory testing is ___________ to make clinical diagnosis.
necessary
Skin is the bodies ________ organ system
largest
Epidermis:
outer highly differentiated layer
Dermis:
inner supportive layer, connective tissue or collagen, elastic tissue
Beneath the epidermis and dermis layers there is a subcutaneous layer of what?
adipose tissue
The subcutaneous layer of adipose tissue does what?
Stores fat for energy, provides insulation for temperature control and aids in protection
Skin color is derived from:
Melanin – brown
Carotene – yellow
Vascular bed – red/purple
Increased melanin ___________ risk for skin cancer
decreases
Skin key facts:
Protection from environment
Prevents penetration
Perception
Temperature regulation
Identification
Communication
Wound repair
Absorption and excretion
Production of vitamin D
Sebaceous glands
Sebum (secreted lipid substance through hair follicles)
Lubricate skin and form emulsion
Sweat glands are important for what?
fluid balance and thermoregulation
Eccrine glands are found where?
all over the surface of the body
(most numerous on the palms of hands and soles of feet)
Eccrine glands produce what?
sweat
Apocrine glands produce what?
milky secretion into hair follicles
Apocrine glands are most commonly found where?
in the armpits and groin area
(sweat from these glands does not evaporate as quickly and can lead to a foul body odor)
Hard plates of keratin are found where?
on dorsal edges of fingers and toes
Common concern questions to ask relating to the skin, hair, and nails:
Past history of skin disease, allergies, hives, psoriasis, or eczema?
Change in pigmentation?
Change in mole (size or color)?
Excessive dryness or moisture?
Pruritus?
Excessive bruising?
Rash or lesions?
Medications?
Hair loss?
Change in nails?
Environmental or occupational hazards?
Skin assessment is integrated throughout what?
physical examination
Scrutinize the _____ skin surface first before you concentrate on underlying structures
outer
Where do you have to separate intertriginous areas (areas with skinfolds)?
under large breasts, obese abdomen, and groin
(inspect them thoroughly)
When assessing the skin, hair, and nails, make sure to always inspect:
feet, toenails, and between toes
Assess skin as ____ entity
one
(getting overall impression helps reveal distribution patterns)
What to look for when assessing skin color:
General pigmentation, freckles, moles, birthmarks
Widespread color change
Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow).
Note if color change is transient or due to pathology.
What to look for when assessing skin temperature:
Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status.
Hands and feet may be slightly cooler in a cool environment.
Hypothermia or Hyperthermia
(make sure to palpate with the back of your hand!)
When assessing for skin moisture, note if there is?
Diaphoresis or Dehydration
Normal skin feels _______ and ______ with even surface
smooth, firm
(observe for thickened areas [callus formation])
Other things to look for when assessing the skin:
Edema
Fluid accumulation in the interstitial space
Mobility and turgor
Assess skin elasticity
Vascularity or bruising
Presence of tattoos and/or variations
Tanner staging identifies what?
gender patterns of hair distribution
Hair color is due to what?
melanin production
Hair texture characteristics range from?
fine to thick to curly to straight and may be affected by use of hair care products
How to identify lesions in hair:
by looking at scalp and dividing hair into sections
Angle of nail base should be what?
about 160 degrees
Nail thickness should be?
uniform smooth and regular (not brittle or splitting)
Nail color should be?
translucent nail plate to pink nail bed below
How to test capillary refill:
Depress nail edge to blanch and then release, noting return of color (indicates status of peripheral circulation)
Pressure injury staging:
Stage I: Non-blanchable erythema
Stage II: Partial-thickness skin loss
Stage III: Full-thickness skin loss
Stage IV: Full-thickness skin/tissue loss
Deep tissue pressure injury (DTPI)
Senile purpura:
typically affects older patients as their dermal tissues atrophy and blood vessels become more fragile
(the recurrent formation of purple ecchymoses (bruises) on the extensor surfaces of forearms following minor trauma)
