HA Prelims

Nursing Process→assessment, diagnosis, planning, implementation, and evaluation

Although the assessment phase precedes the other phases, the assessment phase is→continuous

Process of collecting subjective and objective data→Assessment

process of analyzing the subjective and objective data→Diagnosis

Developing plan of nursing care and outcome criteria→Planning

Carrying out the plan of care→Intervention

Assessing whether outcome criteria have been met and revising the plan of care if necessary→Evaluation

3 types of Objective data→IPPA, Lab test, Medications

4 types of Subjective data→Biographical Data, History of Personal Health Concern, Family History, Lifestyle and Health Practices

Datas that comes from the patient→Subjective Data

X-Ray of patient→Lab test

Urinalysis→Lab test

Severity of pain→Subjective Data

IPPA→Inspection, Palpation, Percussion, Ausculatation

Using the senses of vision, smell and hearing to detect normal and abnormal findings→Inspection

Starts the moment you meet the client→Inspection

Types of Palpation→Light, Deep

1-2cm palpation→Light palpation

4-5cm palpation→Deep palpation

Type of palpation used to assess enlarged organ→Deep Palpation

Type of palpation used to assess for lesions→Light Palpation

Type of palpation used to assess for edema→Deep Palpation

Type of palpation used to assess for temporomandibular joint→Light Palpation

Tapping the body parts to produce sound waves→Percussion

Types of Percussion→Resonance, Dull, Tympanic, Flat

Percussion in Bones→Flat

Percussion in Organs→Dullness

Percussion in Abdomen→Tympanic

Percussion sound of air→Tympanic

Percussion in lungs→Resonance

Percussion in liver→Dull

Percussion in sternum→Flat

Assessment that requires the use of a stethoscope→Auscultation

A soft, pulsatile, whooshing, blowing sound→Bruiting sounds

Phases of Interview→Pre-introductory, Introductory, Working, Concluding

Phase of interview wherein nurse and client is collaborating to identify problems and goals→working

Phase of interview wherein the nurse is reviewing the client's medical data→Pre-introductory phase

Phase of interview wherein the nurse tells client his/her name→Introductory phase

Phase of interview wherein the nurse develops trust and rapport with the client→Introductory

Phase of interview wherein the nurse and client collaborates to identify the underlying problems→Working phase

Phase of interview wherein the nurse asks the client for follow-up or questions they might have in mind→Concluding

Known as termination phase→Concluding phase

COLDSPA→Character, Onset, Location, Duration, Severity, Pattern, Associated Factors

The largest organ of the body→Skin

Outer layer of the skin→Epidermis

Parts of Epidermis→Stratum Corneum, Stratum Lucidum, Stratum Granulosum, Stratum Germinativum

Part of epidermis that contains dead keratinized cells→Stratum Corneum

Part of epidermis that is thin and has clear zone that is present certain areas of body→Stratum Lucidum

Part of epidermis wherein the cytoplasms are full of granules→Stratum Granulosum

Part of epidermis where mitosis happen→Stratum Germinativum

Part of epidermis that contain melanin→Stratum Germinativum

Made of keratinized stratified squamous epithelium tissue→Epidermis

Replaced every 3-4 weeks→Epidermis

Does not contain any blood vessels→Epidermis

Inner layer of the skin→Dermis

Dermis is composed of {{9303294988307749::Collagen}} Fiber and Few Elastic Fibers

Connects the dermis and epidermis→Dermal Papillae

Creates ridges known as fingerprints→Dermal Papillae

Causes goosebumps→Arrector Pili Muscle

Creates Sebum→Sebaceous Glands

Waterproofs the hair and the skin→Sebum

Gets damaged when using strong shampoo→Sebum

Types of Sweat Glands→Eccrine and Apocrine Glands

Thermoregulation→Eccrine Glands

Secretion of Sweat→Eccrine Glands

Secretion of Milky Sweat→Apocrine Glands

Located all over the entire skin→Eccrine Glands

Nonfunctional until puberty→Apocrine Glands

Sweat and bacteria produces {{4937900394653907::Body odor}}

Located beneath dermis→Subcutaneous Tissue

other term of subcuntaneous tissue→Hypodermis

Made up of loose connective tissue→Subcutaneous Tissue

Connects the skin to underlying structures→Subcutaneous Tissue

Stores fat as energy reserve→Subcutaneous Tissue

Layers of keratinized cells→Hair

Types of hair→Vellus, Terminal

Short, Pale, Fine, Present over much of the body→Vellus Hair

Scalp and Eyebrows→Terminal Hair

Located in distal phalanges→Nails

Fair skinned people have more {{31623465124952443::Vitamin D}} to be absorbed from reduced sunlight

Fair skinned has the highest risk of developing→Skin Cancer

How to assess skin turgor→By pinching the skin

Pain upon touching→Tenderness

abnormally thin→Cachectic

loss of fat in the face→Emaciated

Manner of walking→Gait

Uncoordinated and unsteady walking (parang lasing)→Ataxic Gait

Small, Dragging steps→Shuffling Gait

Parkinson's Disease→Shuffling Gait

Walking with difficulty→Limping

Poikilothermia→Inability to regulate body tempreture

Tubig sa baga→Pleural Effusion

Accumulation of fluid in Peritoneum Cavity→Ascites

Enlargement of liver→Hepatomegaly

Enlarged spleen→Splenomegaly

Cardiomegaly→Enlargement of Heart

Nephromegaly→Enlargement of Kidney

Thyromegaly→Enlargement of Thyroid Glands

Gastromegaly→Enlargement of Stomach

weakened, bulging blood vessel that may rupture, causing severe bleeding→Aneurysm

Paralysis of the facial nerve (7)→Bell's Palsy

Largest salivary gland→Parotid Gland

Gland that makes most (70%) of the saliva→Submandibular Glands

Cervical vertebrae 7→Prominence Vertebrae

Cervical vertebrae 1→Atlas

Cervical vertebrae 2→Axis

Connects right and left lobes of thyroid glands→Isthmus

Largest endocrine gland→Thyroid Gland

Regulates Metabolic Rate→Thyroid Gland

Adam's apple is made of→Thyroid Cartilage
Flat, non-palpable lesion, less than 1cm→Macule

Flat, non-palpable lesion, more than 1cm→Patch

Elevated, palpable lesion, less than 0.5→Papule

Elevated, palpable lesion, more than 0.5→Plaque

Palpable lesion, contains fluid, less than 0.5→Vesicle

Palpable lesion, contains fluid, more than 0.5→Bulla

Elevated, caused by movement of serous fluid into the dermis→Wheal

Pus-filled vesicle or bulla   ex. Acne→Pustule

Fluid filled or semisolid mass that is located in the subcutaneous or dermis→Cyst

Loss of superficial epidermis that does not extend to the dermis→Erosion

Skin mark left after healing of wound or lesion→Scar (Cicatrix)

Skin loss extending past dermis→Ulcer

Linear cracks in the skin→fissure

Round red or purple macule→Petechiae

Round or irregular macular lesion→Ecchymosis

Localized collection of blood→Hematoma

Papular and round, small, red bumps on your skin that are harmless to your overall health→Cherry Angioma

Red Arteriole lesion with central body with radiating branches→Spider Angioma

Bluish or red lesion with varying shape→Telangiectasis

African Americans are rich in {{32942254880929744::Melanin}}

reddening of the skin→Erythema

bluing of the skin→Cyanosis

Paling of the skin→Pallor

Yellowing of the skin→Jaundice

occurs when special cells in the skin make too much of the pigment called melanin→Hyperpigmentation

Occurs when melanin is not absorbed by newborn properly, Hereditary→Birthmarks

soft, fine hair covering a fetus or newborn→Lanugo

Grayish blue nevus or congenital dermal melanocytosis  →Mongolian Spots

3rd to 4th day of newborn→Jaundice Appears

7th to 8th day of newborn→Jaundice Disappears

Cause of Jaundice of newborn→Mother's blood dies, Hemoglobin Catabolism occurs

a small patch of light brown color on the skin, often becoming more pronounced through exposure to the sun→freckles

also called a milk spot or an oil seed, is a clog of the eccrine sweat gland→Milia

totally normal to newborns→Milia and Nevus Simplex

Acanthosis Nigricans→Common to obese people

Senile Lentigines→Common among the aged

Death of Melanocytes→Hypopigmentation

is a disease that causes loss of skin color in patches (Partial)→Vitiligo

Disease of people born without melanocytes→Albinism

→Vernix Caseosa

Vasoconstriction of the newborn caused by Cold tempreture→Cutis Marmorata

Bluish discoloration of hands and feet, Vasoconstriction→Acrocyanosis

Pespiration starts→After 1 month

Infant's Hypodermis are not yet {{7231189298538039::developed}}

straight skin lesion→Linear

Circular skin lesion→Annular

Lesions grouped together→Clustered

Individual and distinct lesion→Discrete

Coin-shaped lesions→Nummular

Small lesions grouped together to form large lesion→Confluent

Parallel ridges running lengthwise→Longitudinal Ridging

Nails that half white and pink, are commonly seen in people with→chronic renal diseases 

Seen with people with psoriasis→Pitting

Spoon shaped nails, may be seen to people with iron deficiency, or endocrine, or cardiac disease→Koilonychia

This may be seen to people with AIDS and respiratory syndrome→Yellow Nail Syndrome

nail inflammation that may result from trauma, irritation or infection→Paronychia

Non-blanchable erythema of intact skin→Stage 1 pressure injury

Partial thickness loss of skin, Adipose fat is not visible and deeper tissues are not visible→Stage 2 pressure injury

Full thickness loss of skin, slough or eschar may be visible→Stage 3 pressure injury

Full thickness skin and tissue loss, palpable fascia, muscle, tendon, ligament, cartilage, or bone in ulcer→Stage 4 pressure injury

Deep,constant pain. occurs with or after cold→Sinus Headache

Stabbing pain, localized in the eye→Cluster Headache

Dull and tight pain, lasts days, months or years→Tension Headache

Accompanied with nausea, vomiting, and sensitivity to light and sound. Affects only one side of face⇒→Migraine Headache

Aggravates by coughing, sneezing, and sudden head movements→Tumor-related Headache

Enlargement of facial features, hands, and feet→Acromegaly

Present with moon-shaped face with reddened cheeks and increased facial hair→Cushing Syndrome

A tightened, hard face with thinning facial skin→Scleroderma

Exophthalmos→Hyperthyroidism

One sided facial paralysis→Bell's Palsy

Dull puffy face  ex.Myxedema→Hypothyroidism

Enlargement of Thyroid Gland→Goiter

Shuffling Gait, mask-like facial appearance→Parkinson's Disease

Neurologic damage, the symptoms depends in the part of brain affected→Cerebrovascualar Accident

Other terms for strech marks→Striae