exam 2review 216

CHPATER 8: ASSESSING SKIN, HIAR, NAILS

Sweat Glands

§  Eccrine glands  produce an odorless fluid to maintain body temperature and produce sweat.

§  Apocrine glands  produce a body odor when reacting to bacterial decomposition and increases in response to emotional stress.

DIAGNOSTICS

Skin biopsy is a procedure to obtain a sample of skin for examination under a microscope.

Use the OPQRST mnemonic (Onset, Provokes/Palliates, Quality, Radiates/Region, Severity, Timing) to identify the attributes of a symptom.

Skin Disorders

§  Acne  an inflammatory disease of the sebaceous follicles of the skin.

§  Skin Cancer  a malignancy of the cells.

§  Eczema  a chronic inflammatory skin disorder that causes the skin to become scaly, itchy, inflamed, and irritated.

§  Lupus  a systemic autoimmune disease that occurs when the body’s immune system attacks their own tissues and organs, characterized by a distinctive facial butterfly rash unfolding across both cheeks.

§  Psoriasis  a chronic immune disorder that causes the skin to develop silvery, scaly plaques.

§  Seborrhea dermatitis  an inflammatory skin condition causing flaky, yellow scale to form on the scalp, ears, and face.

Changes in Skin Color

§  Albinism  inherited disorder caused by the total or partial absence of an enzyme that produces melanin.

§  Carotenemia  yellowing of the skin due to increased dietary intake of carotene in the diet, from foods such as carrots, sweet potatoes, pumpkin, corn, yams, spinach, and beans.

§  Central cyanosis  bluish discoloration to the skin related to decreased circulating oxygen; best assessed in the oral mucosa, conjunctiva of the eyes, lips, and tongue.

§  Erythema  Red, pink skin color; may indicate inflammation, fever, or increased blood flow. In carbon monoxide poisoning, the individual will have a bright red cherry face and upper trunk.

§  Jaundice  Yellowing of the skin due to excessive levels of bilirubin in the blood.

§  Hyperpigmentation  Darker skin color.

§  Hypopigmentation  Lighter skin color.

§  Pallor/Pale  pale skin is seen in anemia, a decrease in circulating red blood cells or blood flow, or absence of oxygenated blood.

§  Peripheral cyanosis  A blue, gray, slate, or dark purple discoloration of the skin or mucous membranes caused by deoxygenated or reduced hemoglobin in the blood; may occur with decreased cardiac output.

§  Vitiligo  Autoimmune disorder that causes smooth, white patches of skin all over the body.

Keloid formation is an overgrowth of connective tissue and commonly seen on dark skinned individuals.

Conditions Affecting Skin Texture

§  Autoimmune diseases  Can cause inflammation, redness, loss of hair, and changes in skin texture.

§  Acne vulgaris  A skin condition originating from sebaceous glands that can cause blemishes, cysts, bumps, pustules, and inflammation of the skin.

§  Eczema  Causes chronic inflammation of the skin; itchy, dry, scaly patches of skin; this skin disorder has familial tendencies.

§  Hormonal conditions  Can change the texture of skin to be dry, oily, or moist; may change skin color.

§  Rosacea  An inflammatory skin condition causing redness, swelling, and spider-like blood vessels to develop on the middle of the face.

Primary Skin Lesions

§  Macule  Freckle, a circular, small, flat, nonpalpable spot less than 1 cm in diameter.

§  Papule  elevated nevus, appears rough in texture, < than 1 cm.

§  Plaque (psoriasis): A patch of closely grouped thickened papules, > than 1 cm across. Plaque is red, brown, or pink in color with a rough texture.

§  Vesicle Blister, herpes zoster, herpes simplex, serous fluid-filled, < than 1 cm in diameter. Possible infection

§  Nodule  WARTS solid and elevated, > than 1.5 cm.

§  Pustule  ACNE, a raised; circumscribed vesicle filled with pus.

§  Bulla  friction blister, elevated, circumscribed, fluid filled.

§  Wheal  Hives/insect bite, is defined by raised swelling, red bumps, or welts, and itchy skin. Wheals are red in color and are usually caused by an allergic reaction.

§  Telangiectasia (rosacea) are small, dilated blood vessels that occur near the surface of the skin.

§  Tumor  Epithelioma, solid mass.

§  Patch: Irregular, flat, nonpalpable macule.

Secondary Skin Lesions

§  Scale  psoriasis/dandruff; flakes of skin that exfoliate.

§  Crust  scab; dried blood, serum, pus.

§  Excoriation (chronic incontinence)  crusted area with loss of the epidermis.

§  Erosion  Ruptured Vesicle; lost epidermis, moist surface, no bleeding.

§  Ulcer  pressure injury; loss of epidermis and dermis with possible bleeding, scarring.

§  Fissure  Tinea pedis; a linear crack or break in the skin.

§  A scar is discolored fibrous tissue that appears over healed surgical incisions and wounds. Scars can be red, blue, white, and silver in color.

§  A keloid is created by excessive collagen production extending beyond the original boundaries of a wound or incision. It is thick and raised.

Moles

Nevi is plural for nevus. Normal Finding

§  Atypical moles are called dysplastic nevi or Clark’s nevi. They are larger with irregular, poorly defined borders. Color varies between shades of brown, tan, and pink. They have a greater potential for developing into melanoma.

§  Congenital nevi are present at birth. > than 10 cm and are categorized as small, medium, or giant in size. Color is usually tan, brown, red, or shades of black.

Intertriginous areas (under folds of skin) must be inspected !

FOCUSED ASSESSMENT: Inspecting and Palpating the Skin - ABCDE

§  Assess for cyanosis in the lips, oral mucosa, tongue, and extremities.

§  Assess for pallor of skin in the lips, fingernails, and mucous membranes.

§  Assess for jaundice of skin in the lips, sclera of the eyes, and across the rest of the body.

Hyperhidrosis is excessive sweating of the body or hands, palms, armpits, feet, or face, due to an increased number of sweat glands.

Cherry angioma (normal) is a benign, cherry red papule, of compressed blood vessels; commonly seen in individuals older than 30 years of age.

ABNORMAL FINDINGS: Vascular Lesions

§  Ecchymosis  is a bruise caused by bleeding under the skin or mucous membranes.

§  Hematoma  clotted blood within the tissue caused by a break in a blood vessel.

§  Telangiectasia  is caused by vascular dilation of a small group of blood vessels; occurs anywhere on the body but most often on the face and legs.

§  Petechiae  are tiny, pinpoint hemorrhages caused by superficial bleeding from the capillaries of the skin.

§  Purpura  is a hemorrhagic red or purple spot or rash.

ABNORMAL FINDINGS: Skin Cancer Lesions

§  Basal cell carcinoma (Hole in face) presents as a pearl white, dome-shaped papule with overlying random telangiectasia.

§  Squamous cell carcinoma (skin cancer)  is a malignant cutaneous malignancy arising from keratinocytes of the skin or mucosal surfaces; thick, rough, scaly with a crusted surface and irregular borders.

§  Malignant melanoma  develops from a pre-existing lesion usually with an increase in size, change in color or appearance of a nevus.

ABNORMAL FINDINGS: Inspecting and Palpating the Hair and Scalp

§  Alopecia  defined as hair loss, may be due to nutritional deficiencies, medications, illness, endocrine disorders, radiation, or the physiological changes of aging.

§  Alopecia  areata of the scalp, or spot baldness, is a loss of hair in patches involving the scalp or beard; thought to be related to an autoimmune disorder.

§  Folliculitis  is inflammation of a hair follicle developing on the face, arms, legs, or buttocks.

§  Hirsutism  is the excessive growth of thick, dark hair in women where normally the hair does not grow.

§  Seborrhea dermatitis  also called cradle cap in infants, are chronic, greasy scales that accumulate and thicken on the scalp.

§  Tinea capitis  scalp ringworm, is a fungal infection of the scalp causing round, patchy hair loss, pustules, and scale on the skin.

§  Tinea versicolor  also called pityriasis versicolor, is a fungal infection of the skin causing discolored patches or spots occurring anywhere on the body.

ABNORMAL FINDINGS: Inspecting and Palpating the Fingernails and Toenails

Changes in the nail may also indicate a systemic disorder.

§  Beau’s line  is a white, horizontal groove across the nailbed.

§  Onychomycosis  is thickening, yellow discoloration, and scaling of the nailbed due to a fungal infection.

§  Paronychia is a skin infection around the nail causing erythema, swelling, and tenderness at the nail fold.

§  Pitting of nails is a sign of psoriasis; affects both fingernails and toenails; appears as indentations in different sizes, shapes, and depths.

§  Splinter hemorrhages appear as red streaks in the nails, caused by bleeding from capillaries under the nails.

§  Spoon nails are flat or concave; outer edges flare out; dips or waves are visible on the surface of the nail.

CHPATER 9: ASSESSING HEAD, FACE, MOUTH, NECK - OPQRST

REVIEW OF ANATOMY AND PHYSIOLOGY

HEAD

The head is divided into two parts  Cranium & Face; 22 bones that make up the adult skull. Bones of the head and face are connected by connective tissue and immovable joints called sutures.

§  8 cranial bones  frontal (1), parietal (2), temporal (2), occipital (1), ethmoid (1), sphenoid (1).

§  The frontal bone is the most important.

§  Cranial bones meet at meshed immovable joints called sutures; the major skull sutures are the sagittal, coronal, and lambdoidal.

§  Cranial vault is the large part of the skull that protects the brain from injury. It consists of flat bones and acts like a helmet to the brain.

FACE

§  Temporal artery  is a major artery of the head that branches from within the external carotid artery.

§  Temporomandibular joint  a hinge joint connecting the upper temporal bone (part of the skull) and the mandible, the lower jawbone.

§  Parotid glands  largest salivary glands that secrete saliva into the mouth through the Stensen’s ducts.

§  Submandibular gland  lower mandible; this gland drains saliva through the Wharton’s ducts into the lower oral cavity.

SINUSES

 4 Paranasal Sinuses

§  Frontal above the eyes.

§  Ethmoids are between the eyes.

§  Sphenoids are behind the nasal cavity.

§  Maxillary sinuses are the largest; located in the cheekbones below the eyes.

Rhinorrhea is a thin watery clear discharge from the nose.

NOSE

§  Two nostrils (nares)  are lined with mucous membranes.

§  Nasal septum  is midline; made up of cartilage and many blood vessels (Kiesselbach area); CN I Olfactory (smell).

§  Turbinates  (superior, middle, inferior) are bony structures covered by soft mucosa.

§  Adenoids  clusters of lymphatic tissue behind the nose.

§  NASAL FLARING  visible enlargement of the nostrils with inhalation.

MOUTH

§  Oral mucosa  is the mucous membrane epithelium lining inside the mouth.

§  Lips  mark the transition of mucous membrane of the mouth to skin.

§  Cheeks (buccal mucosa)  are the lateral walls of the mouth.

§  Soft palate  closing off the nasal passages during the act of swallowing.

§  Hard palate  is a thin, horizontal plate of the skull, roof of the mouth.

§  Jaw bone (mandible)  the largest and strongest bone of the face.

§  Three salivary glands  (parotid, submandibular, and sublingual) secrete saliva to start the process of digestion and moisten the mucosa.

§  Stensen’s ducts (parotid duct)  the upper buccal mucosa; this is the route saliva flows from the parotid gland into the mouth.

§  Wharton’s ducts  lower oral cavity; transport saliva produced in the submandibular gland and drain saliva produced by the sublingual glands.

§  Teeth  rooted in the gums; 32 permanent teeth in an adult.

§  Gingiva (gums)  covered by mucous membranes, tough insoluble protein mucosa.

§  Tongue  floor of the mouth; organ of taste; covered with moist mucosa; there are arteries, veins, and nerves in the tongue.

THROAT

§  Nasopharynx  behind the nose.

§  Oropharynx  back of the mouth.

§  Laryngopharynx  pharynx, larynx, trachea, esophagus.

§  Trachea  windpipe.

§  Epiglottis  flap that separates the trachea from the esophagus; prevents aspiration of food and fluids.

§  Tonsils  back of the pharynx.

DIAGNOSTICS  CT, MRI, TSH, Thyroid Ultrasound, Throat Culture

NECK

§  Sternocleidomastoid and trapezius muscles  major muscles that support the neck.

§  Hyoid bone  horseshoe-shaped bone between the chin and the thyroid cartilage.

§  Thyroid cartilage  is the largest cartilage of the larynx (the voice box); Adam’s apple.

§  Cricoid cartilage  a ring of cartilage around the trachea.

§  Larynx  between the trachea and the base of the tongue; voice box.

§  Trachea (windpipe)  is made up of cartilage and membranes.

§  Thyroid  butterfly-shaped gland in the anterior portion of the neck.

§  Carotid arteries  each side of the neck; transport oxygenated blood supply to the brain.

§  Jugular veins  bilaterally on each side of the neck; these veins transport deoxygenated blood.

§   Lymph nodes  clusters of lymph nodes are found in the head and neck area.

HEALTH HISTORY

OPQRST Mnemonic

O = Onset

P = Provokes or Palliates

Q = Quality of the pain

R = Region and Radiation

S = Severity

T = Timing

Tension  feeling of pressure in the front of the head or both sides of the head.

Cluster  stabbing pain on one side of the face

Sinus  throbbing pain and pressure in front of the face.

Migraine  vascular headaches with and without an aura; produce unilateral.

ABNORMAL FINDINGS: Head

§  Macrocephaly  abnormally large head size.

ABNORMAL FINDINGS: Inspecting Face

§  Acromegaly  syndrome of growth hormone excess by the pituitary gland.

§  Parkinson’s disease  “masklike” facial appearance.

ABNORMAL FINDINGS: Palpating the Face

§  TMJ  clicking, popping sounds.

ABNORMAL FINDINGS: Nose

§  Nasal Drainage

ABNORMAL FINDINGS: Lips

§  Lips are inverted, swelling, cracking of the skin.

§  Angular cheilitis  inflammation at the corners of the mouth.

§   Angioedema  is edema of the lips.

§   Herpes simplex virus  manifests with cold sores or blisters on the lips.

ABNORMAL FINDINGS: Buccal Mucosa

§  Aphthous stomatitis (canker sore)   inflammatory disease of oral mucosa.

§  Gingivitis  mildest type of periodontal disease.

§  Gingival hyperplasia  enlargement or overgrowth of the gum tissue.

§  Periodontal disease  chronic infection of the gums.

§  Thrush  candidiasis fungal infection that creates thick, white to yellow patches on the tongue.

ABNORMAL FINDINGS: Hard and Soft Palates

§  Torus palatinus  abnormal growth that develops midline in the hard palate.

ABNORMAL FINDINGS: Tongue

§  Atrophic glossitis  smooth red or pink tongue.

§  Hairy tongue  white to dark overgrowth.

§  Leukoplakia  white spots or patches.

§  Squamous cell carcinoma  thickened white or red patch or plaque.

ABNORMAL FINDINGS: Pharynx & Tonsils

§  Tonsillitis  viral or bacterial infection of the tonsils; tonsils become enlarged, swollen.

o   +1 tonsils are visible and slightly protruding

o   +2 tonsils are halfway between the tonsillar pillars and uvula

o   +3 tonsils are almost touching the uvula

o   +4 tonsils are touching each other

§  Pharyngitis  diffuse pharyngeal erythema of the back of the throat.

ABNORMAL FINDINGS: Neck

§  Torticollis  contraction or contracture of the muscles of the neck

ABNORMAL FINDINGS: Thyroid

§  Goiter  enlarged thyroid gland.

ABNORMAL FINDINGS: Auscultating the Thyroid

§  BRUIT  turbulent blood flow is heard related to increased blood flow.

CHPATER 10: ASSESSING EARS

ANATOMY AND PHYSIOLOGY

§  The auricle (pinna)  outer visible portion of the ear.

§  CN VIII  hearing and balance.

DIAGNOSTICS

§  Audiometric testing  assess conductive and sensorineural hearing loss.

§  Tympanometry  middle ear infections

HEALTH HISTORY: MEDICAL HISTORY

§  Presbycusis  sensorineural hearing loss

EARS

§  Tinnitus  perception of sound when no actual external noise is present; “ringing in the ears.”

§  Vertigo  a feeling that the environment is moving.

§  Darwin’s Tubercle  congenital deviation that is a small cartilaginous protuberance on the helix of the ear.

ABNORMAL FINDINGS: EARS

§  Cauliflower ear  repeated trauma or hitting the ear; a blood clot forms under the skin.

§  Microtia  pinna is underdeveloped.

§  Macrotia  large ears.

§  Tophi  hard, whitish, cream-colored.

Assessing Hearing (CN VIII)

§  Conductive hearing loss  outer ear canal to the eardrum.

§  Sensorineural hearing loss  inner ear hearing loss.

§  Mixed hearing loss  conductive and sensorineural hearing loss.

§  Whisper Test  see if patient can hear sounds without seeing the nurse’s mouth.

§  Rinne Test (air conduction)  vibrating tuning fork against mastoid bone and asks the patient to state when the sound can no longer be heard.

o   AC >BC  Positive Rinne is heard twice as long as bone conduction.

o   BC > AC  bone conduction is heard longer than air conduction.

§  Weber Test (bone conductivity)  tuning fork ON TOP of the head and ask the patient if the sound can be heard in the right or left ear.

CHPATER 11: ASSESSING EYES

REVIEW OF ANATOMY AND PHYSIOLOGY

§  Sclera white avascular tissue that protects the eye and maintains the shape of the eye.

§  Aqueous humor  water-like fluid that fills the anterior.

§  Choroid  vascular layer of the eye between the retina and sclera.

§  Iris  the middle layer of the eye.

§  Cornea  dome-shaped, avascular, transparent surface that covers the front part of the eye.

§  Macula  yellow spot in the retina.

§   Optic disc  bright spot on the retina.

§  Retina  multilayered tissue.

HEALTH HISTORY

§  Cataracts  lost vision.

§  Glaucoma  loss of peripheral vision.

§  Macular degeneration  retina causing loss of central vision.

SNELLEN CHART 20/20 distance visual acuity; stand 20 feet away from chart.

ROSENBAUM  close visual acuity; 14 inches from the patients face.

ISHIHARA PLATE  Color blindness.

AMSLER GRID  assess central vision; check whether lines look wavy.

§  Farsightedness (HYPEROPIA)  focusing on near objects.

§  Nearsightedness (MYOPIA)  appear blurred.

§  Diplopia  double vision.

§  Nyctalopia  Night blindness.

ABNORMAL FINDINGS: EYES

§  Exophthalmos  anterior portion of the eyeball.

§  Periorbital edema  swelling in the tissues around the eye.

§  Ectropion  turns outward.

§  Entropion  turns inward.

§  Hordeolum  infection of a follicle of an eyelash.

§  Corneal Abrasion  painful scratch to the clear surface of the eye.

§  Cataract  opacity of the lens caused by aging.

§  Scleral Jaundice  liver disease.

§  Conjunctivitis  bacterial infection; yellow/green drainage.

§  Subconjunctival hemorrhage  broken blood vessels under the clear surface of the eye.

§  Pterygium  abnormal growth of the conjunctiva.

ABNORMAL FINDINGS: Assessing for Visual Acuity (CN II)

§  Myopia  Nearsightedness.

§  Hyperopia  Farsightedness.

§  Presbyopia  progressive loss of the ability to focus clearly on near objects related to aging.

§  Legal blindness  visual acuity of 20/200 or more.

ABNORMAL FINDINGS: Using Confrontation Test for Visual Field Testing (CN III, IV, and VI)

§  Scotoma  area of reduced or absent vision surrounded by an area of normal vision.

§   Hemianopia  when half of the visual field is lost.

ABNORMAL FINDINGS: Six Cardinal Positions of Gaze (CN III, IV, VI)

§  Diplopia  single object becomes doubled.

§  Nystagmus  fixed gaze in the peripheral field.

ABNORMAL FINDINGS  Inspecting Pupil Size and Consensual Pupil Response (CN II and CN III)

§  Anisocoria  unequal size of the pupils.

§  Mydriasis  bilateral dilated and fixed pupils.

§  Miosis  abnormal construction of the pupils.

§  Horner syndrome   affects one side of the face, drooping eyelid.

PERRLA for Pupils are Equal, Round, and React to Light and Accommodation

CHAPTER 12: ASSESSING RESPIRATORY SYSTEM

Upper Respiratory Tract

§  Nose  air enters through the nostrils.

§  Oropharynx  passageway between nose, sinuses, larynx, and trachea.

Lower Respiratory Tract

§  Trachea  windpipe.

§  Bronchi  right and left main bronchi.

§  Bronchioles  gas exchange.

§  Alveoli  air sacs of the lungs.

§  Lungs  two cone-shaped; air filled sacs.

§  Acid-Base Balance  release of carbon from the lungs

§  Pleura  two layers

o   Partial lining  adheres to thoracic wall.

o   Visceral  covers outer surface of the lungs.

§  Thoracic Cage  protects internal organs and supports the upper body.

§  Diaphragm  bottom of the chest cavity.

Lobes of the Lungs

HEALTH HISTORY

§  Asthma

§  COPD  obstructive and progressive lung disease causing inflammation.

§  Cystic Fibrosis  hereditary disease of the exocrine glands.

§  Bronchitis  viral or bacterial infection.

§  Pneumonia  bacterial or fungal infection of the lung.

1 pack of cigarettes (20 cigarettes) daily for 25 years (20/20 x 25) = 25 pack-year history for smoking.

smokes 1/2 pack (10 cigarettes) for 5 years (10/20 x 5) = 2.5 pack-year history for smoking.

BREATHING

§  Dyspnea  shortness of breath.

§  Cardiac dyspnea  inadequate cardiac output.

§  Orthopnea  difficulty breathing.

§  Paroxysmal nocturnal dyspnea  sudden awakening caused by shortness of breath.

§  Conversational dyspnea  inability to speak complete sentences without stopping.

§  Grunting  noisy; difficulty breathing.

§  Eupnea  normal breathing (12- 20) bpm.

COUGH

§  Sputum?

§  Hemoptysis  any blood?

ABNORMAL FINDINGS: Thoracic Cage

§  Retractions  visible “pulling in” of intercostal.

§  Barrel Chest  1:1 ratio, common in COPD patients.

§  Body positioning to facilitate respirations  finds upright posture the most comfortable.

§  Bradypnea  slow respirations.

§  Tachypnea  fast, shallow breathing (more then 20) bpm.

§  Apnea  absence in breathing.

§  Kussmaul Respirations  regular but increase in rate/ abnormally deep.

§  Biot’s Respiration  irregular respirations (shallow).

§  Cheyne-Stokes Respirations  Gradual increase in depth of respirations; periods of deep breathing alternating.

ABNORMAL: Skin Color Related to Respiratory Problems

§  Pursed lip breathing  breathing through the nose and exhaling through pursed lips.

§  Clubbing of nail plates  chronic lack of oxygen or hypoxia.

ABNORMAL: Palpating the Thorax

§  Crepitus  light crackling or popping feeling under the skin caused by leakage of air.

ABNORMAL: Palpating Tactile Fremitus

§  Increased fremitus  increased density of the lung tissue.

§  Decreased fremitus  are obstructed with fluid (pleural effusion).

NORMAL: Percussing Thorax

§  Resonance is the low-pitched, clear, hollow sound.

ABNORMAL: Palpating Tactile Fremitus

§  Dullness sounds are soft and muffled.

o   PNEUMONIA

§  Hyperresonance  low-pitched, drum like

o   ASTHMA

Auscultating the Lungs

NORMAL FINDINGS

§  Bronchial (tracheal)  breath sounds are heard over the trachea.

§  Bronchovesicular  breath sounds are heard over the right and left bronchi.

§  Vesicular  breath sounds are heard throughout the periphery of the lungs.

ABNORMAL: Auscultating the Lungs

§  Crackles.

§  Rhonchi  loud, deep, low pitch wheezing.

§  Wheezes  narrowed passageways.

§   

§  Pleural Friction  deep, loud, harsh.

§  Stridor  harsh, high-pitched, crowing sound.

§  Diminished or absent ch sounds  signs of worsening ventilation and oxygenated.