nurs 210 final

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health survey objective data

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Tags and Description

219 Terms

1

health survey objective data

physical appearance, body structure, behavior, and measurements

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2

objective

data that can be measured

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3

subjective

data from the subject themselves

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4

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

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5

PQRSTU

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

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6

The interview terms

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

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7

verbal communication

words you speak, tone used

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8

nonverbal communication

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

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9

internal factors

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

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10

external factors

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

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11

10 traps of interviewing

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

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12

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

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13

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

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14

skin function

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

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15

inspection and palpation: skin

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

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16

primary lesions

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

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17

secondary lesions

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

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18

vascular lesions

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

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19

COCA

color odor consistency amount

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20

inspection and palpation: hair

color, texture, distribution, lesions,

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21

inspection and palpation: nails

shape and contour, consistency, color, cap refill

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22

clubbing

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

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23

ABCDEF

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

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24

shapes of lesions

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

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25

malignant skin lesions

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

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26

onychomycosis

fungal infection in and around the nail

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27

structure and function: head

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

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28

salivary glands

parotid - in cheeks submandibular - beneath mandible

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29

thyroid

endocrine gland, straddles the trachea, T3 and T4

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30

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

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31

spleen

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

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32

tonsils

palantine, adenoid, lingual; immunity

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33

Hodgkins lymphoma

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

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34

non-Hodgkins lymphoma

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

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35

Mono

enlargement of the spleen, fever, severe malaise

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36

retropharyngeal abcess

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

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37

RA

autoimmune disease, attacks muscles, joints, bones, tendons

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38

AIDS

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

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39

lymph nodes

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

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40

major concerns of headaches

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

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41

inspection and palpation: skull

normocephalic, symmetry, TMJ - crepitus?

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42

bruits

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

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43

plagiocephaly

positional deformation due to sleeping position,

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44

craniosynostosis

premature fusion of the suture lines

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45

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

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46

simple diffuse goiter

iodine deficiency, chronic enlargement of the thyroid gland

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47

parotid gland enlargement

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

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48

hyperthyroidism

Grave's disease; goiter, eyelid retraction, exophthalmos

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49

hypothyriodism

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

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50

cushings

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

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51

Bells palsy

paralysis of the facial nerve - not a stroke

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52

conjunctiva

the clear covering over the entire anterior eyeball

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53

cornea

clear covering over the iris and the pupil

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54

extraocular muscles

CN III,IV, and VI; six muscles;

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55

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

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56

visual reflexes

pupillary light reflex, fixation, accommodation

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57

aging adults: eyes

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

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58

glaucoma

increased intraocular pressure; hispanics and african americans

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59

macular degeneration

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

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60

CN II

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

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61

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

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62

oblique lighting

cornea and lens- smooth and clear iris - flat

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63

pupillary light reflex

direct and consensual

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64

PERRLA

pupils equal, round, react to light and accommodation

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65

optic disc

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

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66

retinal vessels

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

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67

ptosis

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

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68

chalazion

infected or inflammed oil gland on the eyelid

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69

hordeolum

inflammation on the eyelash

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70

anisocoria

unequal pupils, both responsive to light

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71

mydriasis

dilated and fixed pupils

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72

horners syndrome

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

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73

pterygium

overgrowth of the conjunctiva towards the center of the eye

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74

auditory canal

outer 1/3 is cartilage

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75

middle ear functions

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

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76

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

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77

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

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78

inspecting with otoscope

pull pinna up and back

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79

CN VIII and tests

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

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80

polyp

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

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81

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

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82

nasal cavity

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

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83

paranasal sinuses

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

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84

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

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85

periodontal disease

linked to type 2 diabetes

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86

CN IX & X

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

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87

CN XII

hypoglossal, movement of the tongue

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88

choanal atresia

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

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89

angular cheilitis

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

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90

retention cyst

filled with saliva, can be painful

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91

epulis

benign, nontender fibrous nodule of the gum

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92

koplik spots

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

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93

candidiasis

yeast infection - adults with antibiotic therapy

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94

oral kaposi's sarcoma

bruiselike on hard palate, can develop with AIDS

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95

peritonsillar abscess

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

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96

mediastinum

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

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97

trachea and bronchial tree

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

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98

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

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99

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

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100

tuberculosis

bacterial pocket in lungs that calcifies - highly contagious through droplets

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