HA 1

pre-introductory

review ehr before meeting client

identify baseline data

introductory phase

introduce self by professional name

explain purpose and rationale

sit at eye level

working phase

inquire into biographical data

observe non verbal behavior

apply critical thinking

summary and closing phase

review major data gathered during the phase

skin

largest organ of the body

hair

vellus hair provides thermoregulation by wicking sweat away from body

nails

protect the distal ends of the fingers and toes

enhance precise movement of digits

acanthosis nigricans

darkening of skin in body folds and creases

macule

flat, non-palpable color changes

papule

elevated, palpable, solid masses

nodule

solid masses extending deeper into the dermis

vesicle

elevated lesions with serous fluid

wheal

transient areas of localized dermal edema

cyst

encapsulated fluid-filled masses

erosion

loss of superficial epidermis

fissures

linear cracks

lichenification

thickening from chronic rubbing

atrophy

thinning of epidermis

annular/arciform

ring shape with outer border

zosteriform

unilateral dermatomal distributions

tracks along a single nerve pathway

confluent

lesions merge to form continuous sheet

Tzanck smear

examines cytology from freshly unroofed vesicles

to confirm viral infection

wood’s light exam

irradiates skin with long wave UV light

to identify fungal/bacterial infections

clinical photography

document lesion baseline dimensions and wound healing progress

ventilation

movement of air into and out of the lungs

perfusion

blood flow through pulmonary capillaries

diffusion

movement of gases across the alveolar-capillary membrane

oxygen transport

movement of oxygen from lungs to tissues

Vesicular

Low-pitched, gentle sighing sound

LOC: over peripheral lung

Bronchovesicular

Moderate-intensity and moderate pitched.

Blowing sound

LOC: between scapula and lateral to sternum

Bronchial (tubular)

High-pitched, loud harsh sounds

LOC: anterior over trachea

Head bobbing

Involuntary/rhythmic movements of the head

Visual acuity

Measures the sharpness and clarity of vision

Blepharitis

Inflammation of eyelid margins

Anisocoria

Unequal pupil sizes

Nystagmus

Involuntary eye oscillation

Hemianopia

Loss of half of visual field

Scotoma

Localized visual loss