nurs 210 final

health survey objective data

health survey objective data

physical appearance, body structure, behavior, and measurements

objective

data that can be measured

subjective

data from the subject themselves

health history sequence

biographic data, source of history, reason for seeking care, HPI, past health, family history, review of systems (only talk about it), ADLs

PQRSTU

provocative/palliative quality(sharp stabbing pain)/quantity(pain scale) region/radiation severity scale timing/onset understand patient's perception of problem

The interview terms

location, explanation, purpose, time frame, participation, confidentiality, cost,

verbal communication

words you speak, tone used

nonverbal communication

body language, physical appearance, posture, gestures, facial expression, eye contact, voice, touch

internal factors

liking others, empathy, ability to listen, self-awareness

external factors

privacy, avoid interruptions, physical environment, dress, note-taking

10 traps of interviewing

why questions authority professional jargon biased questions unwanted advice distancing false assurance interrupting avoidance language talk too much

SBAR tool

Situation - brief description of the patient Background - pertinent hx as it directly relates to the patient's current health status Assessment - pertinent assessment findings obtained with interpretation of data Recommendation or request - what you need/want for the patient in terms of medical treatment and/or assistance

skin structure

epidermis - keratinized cells, basal cell layer, thinnest layer dermis - inner supportive layer, connective tissue, elastic tissue; nerves, capillaries, hair follicles subcutaneous fat and tissue - temp and energy

skin function

protection, perception, temp regulation, communication, wound repair, absorption and excretion, vitamin D, emotions

inspection and palpation: skin

color, temperature, moisture, texture, thickness, edema, mobility and turgor, vascularity or bruising, lesions,

primary lesions

pathological process; macule, papules, patches, plaques, nodules, wheals, tumors, urticaria (hives), vesicles, cysts, bullas, pustules

secondary lesions

result from another issue; crust, scale, fissures, erosions, ulcers, excoriations, scars, atrophic scars, lichenifications, keloids

vascular lesions

red, pink, purple; hemangioma, telangiectases, purpuric lesions, ecchymosis/bruise/hematoma/contusion

COCA

color odor consistency amount

inspection and palpation: hair

color, texture, distribution, lesions,

inspection and palpation: nails

shape and contour, consistency, color, cap refill

clubbing

160 degrees or less, sign of chronic respiratory illness (COPD)

ABCDEF

asymmetry border irregularity color variations within lesion itself diameter >6mm elevation/evolution funny looking

shapes of lesions

annular, confluent, discrete, grouped, gyrate, target, linear, polycyclic, zosteriform (from shingles - linear and follows a nerve track)

malignant skin lesions

basal cell - looks dry squamous cell - looks like a pimple melanoma - dark spot, genetic

onychomycosis

fungal infection in and around the nail

structure and function: head

cranial bones: frontal, parietal, occipital, temporal; sutures: coronal, sagittal, lambdoid; 14 facial bones

salivary glands

parotid - in cheeks submandibular - beneath mandible

thyroid

endocrine gland, straddles the trachea, T3 and T4

lymphatic system

immune system, lymph nodes; waste to spleen or excrete from body; own vessel system; everything flows to core of body and towards spleen; absorbs lipids in intestinal tract and conserves fluid and plasma proteins; 2 places dont have lymph nodes: brain and uterus

spleen

LUQ; destroy old RBCs, store RBCs, produce antibodies, filter microorganisms

tonsils

palantine, adenoid, lingual; immunity

Hodgkins lymphoma

more rare, enlargement of lymph node in the neck, armpit, and groin; symptoms: fatigue, fever, chills, night sweats

non-Hodgkins lymphoma

abdominal and chest pain; symptoms: fatigue, fever, and swollen nodes

Mono

enlargement of the spleen, fever, severe malaise

retropharyngeal abcess

medical emergency, huge pocket of infection; muffled voice, drooling

RA

autoimmune disease, attacks muscles, joints, bones, tendons

AIDS

CD count of 200; huge hit to immune system because on immunosuppresents

lymph nodes

preauricular, posterior auricular, occipital, submental, submandibular, sublingual, retropharyngeal, anterior posterior and deep cervical chains, supraclavicular

major concerns of headaches

never had one before, thunderclap, onset after age of 50, headache with HTN

inspection and palpation: skull

normocephalic, symmetry, TMJ - crepitus?

bruits

listen over thyroid and carotid arteries using the bell; can be a sign of HTN, cardiac disease, and hyperlipidemia

plagiocephaly

positional deformation due to sleeping position,

craniosynostosis

premature fusion of the suture lines

congenital torticollis

hematoma in one sternomastoid muscle, results in head tilt to one side and limited neck ROM; can also be acquired - stroke, surgery, accident, injury

simple diffuse goiter

iodine deficiency, chronic enlargement of the thyroid gland

parotid gland enlargement

rapid painful enlargement seen in result to mumps, blockage of duct, abscess, or tumor; ear infection, abscessed teeth

hyperthyroidism

Grave's disease; goiter, eyelid retraction, exophthalmos

hypothyriodism

puffy face, puffy periorbital edema, coarse facial features, coarse hair and eyebrows

cushings

increased ACTH, long-term steroid use; moonlike face, red cheeks, hirsutism

Bells palsy

paralysis of the facial nerve - not a stroke

conjunctiva

the clear covering over the entire anterior eyeball

cornea

clear covering over the iris and the pupil

extraocular muscles

CN III,IV, and VI; six muscles;

internal anatomy of the eye

outer fibrous sclera - sclera and cornea middle vascular choroid - choroid, iris, pupil, lens (refracts) inner nervous retina - retina (visual receptive layer), optic disc, retinal vessels, macula

visual reflexes

pupillary light reflex, fixation, accommodation

aging adults: eyes

pupil size decreases presbyopia - far sighted lens becomes thick and yellow cataracts, glaucoma, AMD (macula of retina), diabetic retinopathy

glaucoma

increased intraocular pressure; hispanics and african americans

macular degeneration

caucasians; risk factors: family hx, smoking, hyperopia, light iris color, HTN, hypercholesterolemia, female

CN II

optic verve; visual acuity; Snellen E chart, Rossenbaum, confrontation test

CN III,IV, and VI

oculomotor, trochlear, and abducens; eye muscles that control the movement of your eye in the globe; corneal light reflex, 6 fields of gaze, accommodation

oblique lighting

cornea and lens- smooth and clear iris - flat

pupillary light reflex

direct and consensual

PERRLA

pupils equal, round, react to light and accommodation

optic disc

on nasal side; color, shape, margins, cup-disc ratio

retinal vessels

number, color, A:V ratio (2:3 or 4:5)

ptosis

drooping of the eyelid, lid lag, also used for lazy eye (strabismus)

chalazion

infected or inflammed oil gland on the eyelid

hordeolum

inflammation on the eyelash

anisocoria

unequal pupils, both responsive to light

mydriasis

dilated and fixed pupils

horners syndrome

anisocoria and ptosis on same side; a lesion of the sympathetic nerve

pterygium

overgrowth of the conjunctiva towards the center of the eye

auditory canal

outer 1/3 is cartilage

middle ear functions

conducts sound vibrations, protect inner ear by reducing amplitude, eustachian tube allows equalization of air pressure on each side of TM

conductive hearing loss

mechanical dysfunction of external or middle ear, partial loss; causes: impacted cerumen, foreign bodies, perforated TM, pus or serum in middle ear, otosclerosis

sensorineural hearing loss

signifies pathology of inner ear, CN VIII, or auditory areas of cerebral cortex; increase in amplitude; causes: presbycusis and ototoxic drugs affect hair cells in cochlea

inspecting with otoscope

pull pinna up and back

CN VIII and tests

acoustic; visual acuity; whisper, weber, and rinne (AC>BC)

polyp

growth in the external ear canal or middle ear, has an odor to it

cholesteatoma

overgrowth of epidermal tissue in middle ear, can result after TM perforation, pearly white cheesy appearance, can erode the bone and produce hearing loss

nasal cavity

first 2/3 is cartilage, last 1/3 is bone

paranasal sinuses

lighten weight, lined with ciliated mucous membrane; frontal and maxillary, ethmoid and sphenoid

salivary glands

stensen's - by mollars wharton's - under tongue sublingual - floor of mouth secrete saliva, moistens and lubricates food, starts digestion, cleans and protects the mucosa

periodontal disease

linked to type 2 diabetes

CN IX & X

glossopharyngeal and vagus; speech, swallow, gag, ahh, and taste

CN XII

hypoglossal, movement of the tongue

choanal atresia

congenital bony septum between nasal cavity and pharynx, emergency if bilateral

angular cheilitis

inflammation of lips - ill-fitting dentures, yeast infections - fissures on lip

retention cyst

filled with saliva, can be painful

epulis

benign, nontender fibrous nodule of the gum

koplik spots

small, blue-white spots with irregular red halo scattered over mucosa, early sign of measles

candidiasis

yeast infection - adults with antibiotic therapy

oral kaposi's sarcoma

bruiselike on hard palate, can develop with AIDS

peritonsillar abscess

big giant ball of pus, talking muffled, drooling, medical emergency

mediastinum

middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels

trachea and bronchial tree

protect alveoli from small particulate matter in inhaled air, lined with goblet cells that secrete mucus

4 major functions of the respiratory system

supplying oxygen for energy production, removing carbon dioxide as waste product, maintaining homeostasis of arterial blood, maintaining heat exchange

aging adult - respiratory

decreased vital capacity and increased residual volume; they can't hold as much in their lungs, but they have more that might get stuck in there

tuberculosis

bacterial pocket in lungs that calcifies - highly contagious through droplets