Macule
solely a color change, flat, and circumscribed
<1 cm
examples: freckles
Papule
Something you can feel casued by superfical thickening in the epidermis; elevated lesion of differing color
<1 cm
examples: elevated nevus (mole)
Plaque
Papules coalesce to form surface elevation wider than 1 cm
examples: psoriasis (scaly rash)
Vesicle
filled with serous fluid
superficial < 1 cm
examples: herpes, chicken pox, shingles
Pustule
purulent fluid-filled lesion
-deeper than vesicle
example: acne
Wheal
superficial, raised, transient, and erythematous; slightly irregular shape from edema
example: mosquito bite
Tumor
Elevated, solid lesion
Deep in dermis
> 2cm
example: lipoma, hemangioma
Nodule
Raised, firm lesion
Deeper than papule (in dermis)
1-2 cm
example: xanthoma (yellow", is a deposition of yellowish cholesterol-rich material that can appear anywhere in the body in various disease states)
Cyst
encapsulated fluid-filled cavity in dermis or sub Q
Scale
compact, desiccated flakes of skin, dry or greasy, silvery or white, from shredding of dead excess keratin cells
examples: after scarlet fever or allergic reaction, dry skin
Scar
After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen); permanent fibrotic change
example: healed area of surgery or injury
Keloid
A benign excess of scar tissue beyond site of original injury, surgery, acne, ear piercing, tattoos, infections, burns.
Looks smooth, rubbery, shiny, and "clawlike"
Higher incidence in Black, Hispanics, and Asians
Erosion
Scooped out but shallow depression;
Superficial; epidermis lost; moist but no bleeding; heals without scar because does not extend into dermis
Excoriation
Self-inflicted abrasion; superficial; sometimes crusted; scratches fro intense iching
Fissure
Linear crack with abrupt edges; extends into dermis; dry or moist
example: cheilosis--at corners of mouth cause by excess moisture
Ulcer
Deeper depression extending into dermis, irregular shape; may bled, leaves scar when heals
Evidence Based Assessment
the essential element of the first phase of the nursing process, and involves the collection of data for nursing purposes. Information is collected using the skills of observation, interviewing, physical examination, and intuition and from many sources, i
Assessment
is the collection of subjective and objective data about a patient's health
Diagnosis
What is the purpose of assessment?
Diagnostic reasoning
the process of analyzing health data and drawing conclusions to identify diagnoses
1. Attending to initially available cues, which are pieces
of information, signs, symptoms, or laboratory data;
2. Formulating diagnostic hypotheses, which are tentative ex
cues
which are pieces of information, signs, symptoms, or laboratory data
Critical thinking
the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment.
The process includes:
Identifying relevant information,
Gathering clinical cues,
Completing an assessment,
Setting priorities
Evidence-based practice
systematic approach to practice that uses the best evidence, the clinician's experience, and the patient's preferences and values to make decisions about care and treatment
Complete Database
includes a complete health history and a full physical examination, yielding the first diagnoses
Focused Database
database is used for a limited or short-term problem. It is smaller in scope and more targeted than the complete database
Follow-up Database
evaluates the status of any identified problem at regular intervals to follow up on short term or chronic health problems
Emergency Database
calls for rapid collection of crucial data, which often occurs while performing lifesaving measures
holistic health model
Assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together!
Health promotion and disease prevention
Involve changing people's unhealthy behaviors through a set of positive acts. The focus is on teaching and helping the consumer choose a healthier lifestyle
D
A medical diagnosis is used to evaluate:
A a person's state of health.
B the response of the whole person to actual or potential health problems.
C a person's culture.
D the cause of disease.
interview
A structured interaction between you and the patient. The terms governing this interaction should be stated clearly at the start of the interview so that openness and trust is facilitated.
Your mutual goal is the patient's optimal health!
Communication
The exchange of information so that each person clearly understands the other; based on behavior, conscious and unconscious, remembering that all behavior has meaning
Internal Factors
Are specific to the examiner;
1.liking others
2.expressing empathy
3.the ability to listen
4. self-awareness
External Factors
Relate mainly to the physical setting.
ensuring privacy, preventing interruptions, creating a conducive environment, arranging equal status seating, wearing appropriate attire, and documenting responses via note-taking or an electronic health record witho
Introduction
During the first phase, begin the interview by introducing
yourself and your role
Working Phase
Gather Data.
Start with open-ended questions, which ask for narrative information. Then use closed or direct questions, which ask for specific information in short, one- or two-word
answers
Closing
Signal that the interview is ending, which gives the patient one last chance to share concerns or express himself or herself. Also, briefly summarize what you learned during the interview
10 traps of interviewing
� Providing false assurance or reassurance,
� Giving unwanted advice,
� Using authority,
� Using avoidance language,
� Engaging in distancing,
� Using professional jargon,
� Using leading or biased questions,
� Talking too much,
� Interrupting, and
� Usin
nonverbal communication
Important in establishing rapport and conveying information while providing clues to understanding feelings
� Physical appearance,
� Posture,
� Gestures,
� Facial expression,
� Eye contact,
� Voice, and
� Touch.
C
When preparing the physical setting for an interview, the interviewer should:
A. set the room temperature between 64� F and 66� F.
B. reduce noise by turning the volume on the television or radio down.
C. conduct the interview at eye level and at a distan
B
Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms.
A. 5
B. 7
C. 9
D. 11
C
When addressing a toddler during the interview, the health care provider should:
A. ask the child, before the caretaker, about symptoms.
B. use nonverbal communication.
C. use short, simple, concrete sentences.
D. use detailed explanations.
A
Nonverbal communication is the primary form of
communication for which group of individuals?
A. Infants
B. Preschoolers
C. Adolescents
D. Older adults
Complete health history
Purpose is to collect subjective data.
By combining subjective data with objective data from the physical examination and laboratory studies, you create a database to make a judgment or diagnosis about the individual's health status
ill patients
The health history includes a detailed, chronological record of the health problem
All patients
The health history is a screening tool for abnormal symptoms, health problems, and concerns. It also records health promotion behaviors and coping skills
Biographical Data
First category collected in a complete health history;
Such as the patient's name, date of birth, occupation, primary language, andcommunication needs
Source of History
Second category collected in a complete health history;
Which is usually the patient but may be someone else, such as a relative or interpreter
Reason for Seeking Care
Third category collected in a complete health history;
(Formerly known as the chief complaint.)
In the patient's own words, briefly describe the reason for the visit stating one or two symptoms or signs and their duration
Present Health or History of Present Illness
Fourth category collected in a complete health history;
For a well person, briefly note the general state of health. For a sick person, chronologically record the reason for seeking care.
Symptom Analysis
Character
Onset
Location
Duration
Severity
Pattern
Associated Factors
Pain Assessment
Provocative or Palliative (what makes it worse/better)
Quality or Quantity (For example, is the pain sharp or dull, throbbing?)
Regian or Radiation(Location)
Severity Scale (Numeric pain intensity scale)
Timing (Onset)
Understand Patient's Perception (Act
Past Health Events
Fifth category collected in a complete health history;
Investigate their past, such as illnesses, injuries, hospitalizations, surgeries, and allergies, and current prescribed and herbal medications.
Family History
Sixth category collected in a complete health history;
Gather family information to help detect health risks for the patient, and assist with early screening and periodic surveillance.
Several questions should be added to assess spiritual resources or rel
Review of Systems
Seventh category collected in a complete health history;
Evaluate the past and present health of each body system, double check for significant data that may have been omitted, and assess health promotion practices
Functional Assessment
Eighth category collected in a complete health history;
Finding out about ADLs and IADLs, measuring a person's self-care ability
Instrumental Activities of Daily Living
housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances, nutrition, social relationships and resources; self-concept and coping; and home environment
D
Which of the following is included in documenting a history source?
A. Appearance, dress, and hygiene
B. Cognition and literacy level
C. Documented relationship of support systems
D. Reliability of informant
C
The CAGE test is a screening questionnaire that helps to identify:
A. unhealthy lifestyle behaviors.
B. personal response to stress.
C. excessive or uncontrollable drinking.
D. depression.
C
When recording information for the review of systems, the interviewer must document:
A. physical findings, such as skin appearance, to support historic data.
B. "negative" under the system heading.
C. the presence or absence of all symptoms under the syst
A
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
A. education, financial status, and value-belief system.
B. exercise and activity, leisure activities, and level of
B
The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
A. review previous medical records.
B. rephrase the same questions later in the interview.
C. ask the p
General Survey
A study of the whole person, covering the general health state and any obvious physical characteristics; Start INSPECTION at moment you first encounter person
It covers four areas: physical appearance, body structure, mobility, and behavior. Changes in an
Physical Appearance
General Survey; includes an assessment of the person's age, sex, level of consciousness, skin color, facial features, and overall appearance
Body Structure
General Survey; addresses stature, nutrition, symmetry, posture, position, body build or contour, and any obvious deformities
Mobility
General Survey; concerned with gait, range of motion, and the presence of involuntary movement
Behavior
General Survey; considers facial expression, mood and affect, speech, dress, and personal hygiene
Body Mass Index
Practical marker of optimal healthy weight for height and an indicator of obesity or malnutrition
Oral route
accurate and the most convenient way to take temperature
If just taken hot or cold liquids-
? WAIT 15 minutes
If just smoked,
? Wait 2 minutes
Rectal route
The most accurate route to take temperature, and the result is as close to core temperature as possible without using more invasive measures
tympanic route
senses infrared emissions of the eardrum, so it is an accurate measurement of core temperature
temporal artery thermometer
uses infrared emissions from the temporal artery and provides an average of multiple readings of temperature.; There are conflicting reports regarding its accuracy
Rate
1 of 3 qualities when palpating for pulse; Normally ranges from 50 to 95 beats per minute but varies with age and gender
Normal Adult: 60-100
Normal Child: 80-110
Normal Infant: 60-160
Rhythm
1 of 3 qualities when palpating for pulse; normally has an even, regular tempo
Force
1 of 3 qualities when palpating for pulse; shows the strength of the heart's stroke volume
1+ Weak, Thready
2+ NORMAL
3+ Full, Bounding (increased stroke volume)
Respirations
Relaxed, regular, automatic, and silent. The normal rate varies with the patient's age, and the ratio of the pulse rate to respiratory rate commonly is 4:1.
Systolic pressure
The maximum pressure felt on the artery during left ventricular contraction (or systole)
Diastolic pressure
The elastic recoil (or resting) pressure the blood exerts constantly between contractions.
Pulse Pressure
The difference between the systolic and diastolic pressures and reflects the stroke volume.
Mean Arterial Pressure
The pressure forcing blood into the tissues, averaged over the cardiac cycle.
oxygen saturation
A sensor attached to the individual's finger or earlobe has a diode that emits light and measures light absorption of pulsatile flow.
Term referring to the concentration of oxygen in the blood. It measures the percentage of hemoglobin binding sites in the
B
The Doppler technique:
A. is used to assess the apical pulse.
B. augments Korotkoff sounds during blood pressure measurement.
C. provides an easy and accurate measurement of the diastolic pressure.
D. measures arterial oxygenation saturation.
A
The tympanic membrane thermometer (TMT):
A. provides an accurate measurement of core body temperature.
B. senses the infrared emissions of the cerebral cortex.
C. is not used in unconscious patients.
D. accurately measures temperature in 20 to 30 seconds.
B
Endogenous obesity is:
A due to inadequate secretion of cortisol by the adrenal glands.
B caused by excess adrenocorticotropin production by the pituitary gland.
C characterized by evenly distributed excess body fat.
D a result of excessive secretion of g
D
The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause?
A. Dehydration
B. Shock
C. Bleeding
D. Anxiety
Accurate Blood Pressure
The width of the cuff 's rubber bladder should equal 40% of the circumference of the person's arm.
The length of the bladder should equal 80% of this circumference.
Pain
A highly complex and subjective experience that originates from the central nervous system or peripheral nervous system or both.
Nociceptive Pain
Develops when functioning and intact nerve fibers in the peripheral and central nervous systems are stimulated.
It starts outside the nervous system from actual or potential tissue damage.
Four phases: transduction, transmission,
perception, and modulatio
Neuropathic Pain
Does not adhere to typical and predictable phases.
It implies an abnormal processing of the pain message as a result of an injury of the nerve fibers.
It is sustained on a neurochemical level.
Visceral Pain
Pain that originates from larger internal organs, such as the stomach, intestines, gallbladder, and pancreas
Somatic Pain
Pain that originates from musculoskeletal tissues or the body surface
Deep Somatic Pain
Pain that comes from sources such as blood vessels, joints, tendons, muscles, and bone
Cutaneous Pain
Pain that is derived from the skin and subcutaneous tissues
Referred Pain
Pain that is felt at a particular site but originates
from another location.
Acute pain
Pain that short-term and self-limiting, often follows a predictable track, and dissipates after the injury heals.
A self-protective purpose; it warns of actual or threatened tissue damage
Chronic Pain
Pain that continues for 6 months or longer. It results from abnormal processing by pain fibers from peripheral or central sites and does not stop when the injury heals.
The level of pain intensity does not reflect the physical findings
Breakthrough pain
A transient spike in pain level in an otherwise controlled pain syndrome or the result of incident or episodic pain
A
Which of the following statements regarding cultural/racial differences in the treatment of pain is true?
A. White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.
B. Black and Hispanic individuals have
C
Specialized nerve endings that are designed to detect painful sensations are:
A. synapses.
B. dorsal horns.
C. nociceptors.
D. C fibers.
B
An older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) scale. The nurse should:
A. reassess the pain level in 3 to 4 hours.
B. administer prescribed pain medication.
C. ask the patient to verify th
Nutritional status
Refers to the degree of balance between nutrient intake and nutrient requirements
Affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors.
� Nurse's goal is to determine whether the patient has
optimal
Breastfeeding
Recommended for full-term infants for the first year of life because it is ideally formulated to promote normal infant growth and development and natural immunity
Fat
Required for proper growth and central nervous system development; infants and children younger than two need this
Adolescence
Involves rapid physical growth and endocrine and hormonal changes and requires an increase in calories, protein, calcium, and iron.
Nutritional assessment
-First, it identifies people who are malnourished or are at risk for malnutrition.
-Second, it provides data for designing a nutrition plan to prevent malnutrition.
-Third, it establishes baseline data for evaluating nutritional care.
Nutrition screening
The first step in nutritional assessment
comprehensive nutritional assessment
If screening identifies nutritional risks, the patient
should undergo this: dietary history and clinical information, physical examination, anthropometric measures, and routine laboratory data
24-hour diet recall
The easiest and most popular method for assessing dietary intake
anthropometric measures
To evaluate growth, development, and body composition;
Include height,weight, triceps skin-fold thickness, elbow breadth,arm span, and frame size
Underweight
BMI: <18.5
Healthy Weight
BMI: 18.5-24.9
Overweight
BMI: 25-29.9
Obesity Class 1
BMI: 30-34.9
Obesity Class 2
BMI: 35-39.9
Extreme Obesity Class
BMI: >40
vitamin C deficiency
may have the following clinical manifestations petechiae or ecchymoses, bleeding gums, joint pain, and splinter hemorrhages of the nails.
riboflavin deficiency
may have the following clinical manifestations: nasolabial seborrhea, red conjunctivae, cheilosis, angular stomatitis, and purplish-colored tongue
vitamin B12 deficiency
may have the following clinical manifestations: pale conjunctivae, disorientation, or irritability.
iron deficiencies
may have the following clinical manifestations: pale conjunctivae, angular stomatitis; pale tongue; and brittle, ridged, or spoon shaped nails.
A
Nutritional status is best determined by:
A. serum albumin.
B. clinical manifestations.
C. triglycerides.
D. 24-hour diet recall.
C
Dietary guidelines suggest that overall fat consumption should be:
A. less than 300 mg per day.
B. between 10% and 20% of the total calorie intake.
C. between 20% and 35% of the total calorie intake.
D. mostly trans-fatty acid or saturated fat.
A
A comprehensive nutritional assessment always includes:
A. anthropometric measures.
B. a direct observation of feeding and eating processes.
C. a work history.
D. a comprehensive metabolic panel.
D
Obese persons with more fat in the upper body, especially the abdomen, have:
A. gastronomic obesity.
B. gynoid obesity.
C. anthropometric obesity.
D. android obesity.
Skin
The body's largest organ system. It acts as the sentry that guards the body from environmental stress and adapts to other environmental influences
Epidermis
skin's thin, tough outer layer
Dermis
inner supportive layer of skin
Subcutaneous Layer
the adipose tissue below the dermis
Epidermal Appendages
hair, sebaceous and sweat glands, and nails
Skin Functions
It offers protection, prevents penetration, allows perception, regulates temperature, allows identification, allows communication of emotions, repairs wounds, absorbs and excretes some metabolic wastes, and produces vitamin D
immature skin of infants
skin that cannot effectively prevent fluid loss or regulate temperature
Aging Skin
causes changes in the stratum corneum that give chemicals easier access to the body, change hair distribution, and cause other changes that lead to
wrinkling
D
A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic?
A. There are two types of sweat gla
C
Risk factors that may lead to skin disease and breakdown include:
A. loss of protective cushioning of the dermal skin layer.
B. decreased vascular fragility.
C. a lifetime of environmental trauma.
D. increased thickness of the skin.
A
What term refers to a linear skin lesion that runs along a nerve route?
A. Zosteriform
B. Annular
C. Dermatome
D. Shingles
A
The components of a nail examination include:
A. contour, consistency, and color.
B. shape, surface, and circulation.
C. clubbing, pitting, and grooving.
D. texture, toughness, and translucency.
A
To determine if a dark-skinned patient is pale, the nurse should assess the color of the:
A. conjunctivae.
B. earlobes.
C. palms of the hands.
D. skin in the antecubital space.
C
An example of a primary lesion is a(n):
A. erosion.
B. ulcer.
C. urticaria.
D. port-wine stain.
D
A scooped-out, shallow depression in the skin is called a(n):
A. ulcer.
B. excoriation.
C. fissure.
D. erosion.
Pallor
Cause? peripheral vascular vasoconstriction - Anemia? Shock ? Arterial insufficiency - Exposure to cold, smoking, stress/fear
Inspect - Generalized pallor?pale or
dull (feels cool to touch) - Check mucous membranes, lips, nail beds - Dark skin? appears as
Cyanosis
Causes: MANY (heart, lungs, shock) Look for other clinical signs (LOC,RR) - Central � Oxygen/hemoglobin deficit - Peripheral � Decreased circulation
INSPECT: light skin? dusky blue (lips, nail beds) � Dark Skin? difficult, dull (conjunctiva, oral mucosa,
Jaundice
Cause - rising bilirubin in blood � Liver dysfunction � Newborn (OK finding @ 3?4 day life)
Inspect: Hard & soft palate (first) � Sclera � Mucous membranes � Skin? late
Erythema
Causes: Many possible etiologies � Excess blood in the dilated capillaries � Fever, local inflammation, emotional reaction
Inspect & Palpate: Temperature of skin (palpate) warmth, tightness or hardening tissue. Dark Skin? palpate for signs of infection
Exudate
Drainage
Serous
Exudate; thin watery, fairly clear drainage--serum
Serosanguineous
Exudate; contains both serous and red blood cells
Sanguineous
Exudate; mostly RBC; looks like blood
Purulent
Exudate; made of white blood cells; pus, color may vary, may have odor
pitting edema
Condition in which interstitial spaces contain such excessive amounts of fluid that the skin remains depressed after palpation
? 1+ Mild Pitting; slight indentation;
? 2+ Moderate pitting; indentation subsides rapidly
? 3+ Deep pitting; indentation remain
Rubella
(German Measles): Pink, popular rash (similar to measles but paler) first appears on face, then spreads. Distinguished from measles by presence of neck lymphadenopathy and absence of Koplik spots
Varicella
Small, tight vesicles first appear on trunk and spread to face, arms, and legs (not palms or soles). Vesicles erupt in succeeding crops over several days; they become pustules and then crusts. Intensely pruritic (itchy)
Impetigo
Moist, thin-roofed vesicles with thin, erythematous base. Rupture to form thick, honey-colored crusts. Highly contagious bacterial infection of skin; most common in infants and children. Infection can spread to other body areas and other children and adul
Annular
circular lesion, begins in the center and spreads to periphery
Confluent
lesions run together
Discrete
distinct lesions, individual lesions that remain separate
gyrate
twisted, coiled, snakelike lesions
grouped
clusters of lesions
linear
a scratch, streak, line or striped lesion
target
or iris lesion, resembles iris of the eye, concentric rings color in lesions
zosteriform
linear arrangement along a unilateral nerve route
polycyclic
annular lesions grow together
lichenification
prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules, looks like surface of moss
pattern injury
bruise or wound whose shape suggests that an instrument or weapon caused it
hematoma
bruise you can feel
Basal cell carcinoma
The most common type of skin cancer; the lesion is a pearly-colored papule with a translucent surface and telangiectasias (broken blood vesssel).
Diaphragm
what part of the stethoscope is for high pitched sounds
-breath, bowel, and normal heart sounds
Bell
what part of the stethoscope is for soft, low-pitched sounds
-extra heart sounds or murmurs
Ecchymosis
Bruise
Staging of bruises:
- immediate?24 hrs: red, blue or purple
- 1?5 days: blue to purple
- 5?7 days: green
- 7?10 days: yellow
- 10?14 days: brown to disappear
Nevi
MOLE
Occur anywhere on body
Flat, raised, smooth, rough, hairy
Usually benign
Evaluation of moles
? Asymmetry
? Border irregular
? Color variation
? Diameter > 6mm
? Evolving, elevation, enlargement
BIOPSY? only way to be sure!
Squamous cell carcinoma
common form of skin cancer that develops in the thin, flat squamous cells that make up the outer layer of the skin
A firm, red nodule
A flat sore with a scaly crust
A new sore or raised area on an old scar or ulcer
A rough, scaly patch on your lip that ma
Malignant melanoma
Most serious type of skin cancer, develops in the cells (melanocytes) that produce melanin � the pigment that gives your skin its color
A change in an existing mole; The development of a new pigmented or unusual-looking growth on your skin
Kaposi's sarcoma
A cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat or in other organs.
The patches are usually red or purple and are made of cancer cells and blood cells. The red and purple patches often c
Secondary Prevention
Screening; (discover the problem early before it worsens),
example: self skin self-care exams:
TEACH
?Why self?assessment is important???
?To use mirrors!
?To look at all areas, both sun?exposed & not!
Tinea
ringworm; circular, clear centers, pustules, scales (fungal)
Vitiligo
absence of melanin pigment in patchy areas
Arterial insufficiency
Any condition that slows or stops the flow of blood through your arteries. Arteries are blood vessels that carry blood from the heart to other places in your body.
Venous insufficiency
Vein walls are weakened and valves are damaged. This causes the veins to stay filled with blood, especially when you are standing.
Cellulitis
Common, potentially serious bacterial skin infection.
Appears as a swollen, red area of skin that feels hot and tender.
Nail Clubbing
deformity of the fingers and fingernails associated with a number of diseases, mostly of the heart and lungs
The Brief Pain Inventory
rate pain within the past 24 hours (0-10)
The Short-Form McGill Pain Questionnaire
Rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain