CH 2 Patient Observation- Vital Signs

Question 1

Deliberate use of senses (vision, hearing, smell, touch) to gather information about your patient

Answer 1

Observation

Question 2

Cannot provide definitive diagnostic information; however, provides clues to underlying problems

Answer 2

Observation

Question 3

Using a logical, consistent sequence to create a systemic approach

Answer 3

Observation

Question 4

Pain, grimacing, difficulty breathing observed by facial expressions, use of accessory muscles for breathing, or frequent positional changes

Answer 4

Immediate patient distress or discomfort

Question 5

Central obesity (trunk and face) and fat pads near the collarbone and back of neck

Answer 5

Cushing’s Syndrome

Question 6

State of malnutrition or wasting associated with many chronic diseases

Answer 6

Cachexia

Question 7

Poor hygiene (impaired self-care abilities, lack of resources, presence of wound, underlying diseases, fruity breath smell)

Answer 7

Disagreeable body odor

Question 8

Wheezing, crackles, signs, narrowed arrows (asthma, CHF, tracheal stenosis), COPD, presence of foreign object, secretions partially blocking airway

Answer 8

Sound of Respiration

Question 9

Profuse perspiration indicating body is working to compensate for reduced cardiac output

Answer 9

Diaphoresis

Question 10

Abnormally increased perspiration

Answer 10

Hyperhidrosis

Question 11

Associated with myocardial infarct, hypotension, shock, hyperthermia (faulty thermoregulation), thyroid hyperactivity, anxiety, overactive sweat glands, environmental conditions, patient participation

Answer 11

Diaphoresis

Question 12

Cough typically resolving within 3 weeks or less (upper respiratory tract infection)

Answer 12

Acute cough

Question 13

Cough typically lasting more than 8 weeks

Answer 13

Chronic/Persistent Cough

Question 14

Caused by a relatively benign airway irritant (dust particles) or may indicate the presence of a disease such as asthma, bronchitis, COPD, lung cancer, pneumonia

Answer 14

Presence of cough

Question 15

Atrophy, hypertrophy, impaired motor function, underlying disease (cerebral vascular accident), facial features during rest, movement, incoordination, or abnormal movements

Answer 15

Asymmetry of body parts

Question 16

Largest organ of the body

Answer 16

Skin

Question 17

Provides important preliminary data about the efficiency of the cardiovascular/pulmonary system and may be an indicator of disease, inflammation, infection

Answer 17

Skin Discoloration

Question 18

Bluish-gray discoloration of the skin and mucous membranes

Answer 18

Cyanosis

Question 19

Caused by hypoxia and results in color changes in central aspects of the body and mucous membranes

Answer 19

Central cyanosis

Question 20

Caused by hypoxia with color changes in the nail beds and lips

Answer 20

Peripheral Cynaosis

Question 21

Associated with diseases of cardiovascular and pulmonary system and CNS disorders that impair respiration

Answer 21

Central Cyanosis

Question 22

Associated with decreased cardiac output, exposure to cold (extreme vasoconstriction), and arterial (peripheral vascular disease), or venous obstruction (deep vein thrombosis)

Answer 22

Peripheral Cyanosis

Question 23

Caused by hypoxia from a blocked airway (asphyxiation or choking) with rapid onset of skin color changes initially in face, lips, and nail beds

Answer 23

Acute Cyanosis

Question 24

Caused by bruising (bleeding under the skin) and may be seen anywhere on the body

Answer 24

Ecchymosis

Question 25

New bruises appear bluish purple while older bruises appear greenish yellow; often caused by trauma (falls, sports injury, physical abuse); including patients on blood thinning agents (Coumadin) that tend to bruise easily

Answer 25

Ecchymosis

Question 26

Reddened area of skin caused by increased blood flow (hyperemia)

Answer 26

Erythema

Question 27

Associated with skin irritation or injury, infection and inflammation, redness over a bony prominence warns of the potential development of a decubitus ulcer

Answer 27

Erythema

Question 28

Diffuse redness of face but may involves other body areas

Answer 28

Flushing

Question 29

Related to emotions (embarrassment, anger), physical exertion, fever, and increased temperature of environment

Answer 29

Flushing

Question 30

Caused by impaired liver function (hepatitis, liver cancer)

Answer 30

Jaundice

Question 31

Skin takes on a yellow-orange hue; best observed in the sclera, mucous membranes, and palms of hands and soles of feet

Answer 31

Jaundice

Question 32

Skin takes on a lighter tone (more white with decreased pink hue) than normal for the individual for normal "fair" skin color; for darker skin, apparent by loss of red tones

Answer 32

Pallor (pale)

Question 33

Associated with anemia (low hemoglobin) and impaired circulation; observed in face, palms, mucous membranes, and nail beds

Answer 33

Pallor (pale)

Question 34

Tiny red or purple hemorrhagic spots caused by capillary bleeding with subsequent leakage of blood into the skin; tends to appears in clusters and often seen on ankles and feet but can occur anywhere on the body

Answer 34

Petechiae

Question 35

May be a sign of thrombocytopenia (low platelet count)- reducing counts impair clotting and increase risk of bleeding (can be associated with variety of medications and disorders

Answer 35

Petechiae

Question 36

Varies with age and poor nutritional status

Answer 36

Skin texture

Question 37

May be indicative of pathological changes or trauma

Answer 37

Skin lesions

Question 38

Typically lack hair growth on the legs and display thickening of nails of the fingers and toes

Answer 38

Diabetes mellitus or Atherosclerosis

Question 39

Nails should be pink (light brown in dark skinned individuals) and free of irregularities

Answer 39

Normal circulation and oxygen supply of nails

Question 40

Deep grooved (indented) transverse lines across the nail resulting from disruption of nail growth caused by trauma or disorders such as Raynaud's disease (decreased blood flow to fingers), psoriasis, or infection around nail plate

Answer 40

Beau's Lines

Question 41

Caused by blood under the nail and results from trauma

Answer 41

Black Nails

Question 42

Bulbous swelling of fingertips secondary to proliferation of connective tissue between the nail matrix and distal phalanx accompanied by the nail bed and skin

Answer 42

Clubbing

Question 43

Nails appear bluish gray (cyanotic) and become soft and boggy (spongy)

Answer 43

Clubbing

Question 44

Develops gradually over time and is associated with diagnoses that involve long-standing hypoxia such as congenital heart defects and cardiopulmonary diseases

Answer 44

Clubbing

Question 45

Seen with renal failure

Answer 45

Half-and-half nails (Lindsay's nails)

Question 46

The distal portion of the nail turns red, pink, or brown; there is a distinct line of demarcation between the two halves

Answer 46

Half-and-half nails (Lindsay's nails)

Question 47

Detachment of the nail from the nail bed

Answer 47

Onycholysis

Question 48

Associated with trauma, fungal infections, psoriasis, and overactive thyroid gland

Answer 48

Onycholysis

Question 49

Transverse white lines across the breadth of the nail

Answer 49

Mee's Lines

Question 50

Associated with systemic diseases such as renal failure, Hodgkin's disease, malaria, and sickle cell anemia

Answer 50

Mee's Lines

Question 51

Classically associated with arsenic poisoning

Answer 51

Mee's Lines

Question 52

Characterized by tiny punctate depressions in the nail

Answer 52

Pitting

Question 53

Caused by systemic diseases such as Reiter's syndrome, psoriasis, and eczema

Answer 53

Pitting

Question 54

Tiny hemorrhages creating reddish lines of blood under nail

Answer 54

Splinter Hemorrhages

Question 55

Associated with bacterial endocarditis and trauma

Answer 55

Splinter Hemorrhages

Question 56

Suggestive of pain or structural abnormalities of pelvis, pectoral, or vertebral regions that may interfere with respiratory patterns

Answer 56

Abnormal posture

Question 57

May be associated with CHF, liver failure, lymphedema, or venous insufficiency

Answer 57

Edema

Question 58

May result from varicose veins, thrombophlebitis, or trauma

Answer 58

Localized edema