Exam 1 Flashcards
(216 cards)
1
Q
Nursing diagnosis is concerned with?
A
Impact of of health on the individual and caring
2
Q
SOAP
A
Subjective, objective, assessment, plan
3
Q
Subjective?
A
Symptoms as reported by patient
4
Q
Objective?
A
Observed signs
5
Q
Comprehensive database
A
Traditional H&P
6
Q
Episodic databse
A
Problem centered
7
Q
Follow Up Database
A
Problem centered, f/u on stable patient
8
Q
Emergency Database
A
ABCs
9
Q
Components of classic H&P
A
Chief complaint, history of present illness, past medical history, current health history, social/occupational/family history, functional assessment, review of systems, physical exam
10
Q
Analyze symptom using…
A
PQRSTU. Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity Scale, Timing, Understand
11
Q
Para
A
of live births
12
Q
Gravata
A
of pregnancies
13
Q
BMI formula
A
weight (kg) / height (m) squared
14
Q
Average oral temp
A
37 degrees c
15
Q
average pulse rate
A
60-100
16
Q
Average respiration rate
A
10-20
17
Q
Average blood pressure
A
120/80
18
Q
What can high bp lead to?
A
Heart failure, left ventricular hypertrophy, stroke, ischemic attack, chronic kidney disease, peripheral arterial disease, retinopathy
19
Q
Ausculatory gap
A
silent interval that may be present between systole and diastole
20
Q
Orthostatic hypertension
A
Drop in systole of 20 or pulse increase of 20 when changing positions (sit -> stand)
21
Q
Canthus
A
corner of eye
22
Q
caruncle
A
pink tissue in medial canthus
23
Q
limbus
A
dark line surrounding iris
24
Q
tarsal plate
A
strips of connective tissue that gives eye shape, contains meibomian glands which secrete oily lubricant
25
Palpebral conjunctiva
lines eyelids
26
Bulbar conjunctiva
Overlays eyeball anteriorly
27
Lacrimal apparatus
Constantly irrigates eye, tears drain into the puncta which drains into nasolacrimal sac which drains into inferior meatus
28
Sclera
fibrous layer of eye
29
Choroid
Vascular layer of eye
30
Retina
nervous layer of eye
31
What can you see in ophthalmoscope view?
4 sets of retinal vessels, retinal field, optic disc, macula
32
Optic disc
on the nasal side of retina, where fibers converge to form optic nerve (CNII), blind spot because no receptors
33
Macula
on the temporal side of the retina, surrounds fovea centralis (point of sharpest vision)
34
How many extrocular muscles?
4 rectus, 2 oblique
35
Which cranial nerves innervates the lateral rectus muscle?
CNVI (abducens) and abducts eye
36
Which CN innervates the superior oblique muscle?
CN IV (trochlear), down and towards nose
37
Which muscles does CNIII innervate?
Oculomotor, all the muscles except superior oblique and lateral rectus muscle
38
Visual pathway
light off object --> retina --> optic nerve --> optic chiasm --> optic tract --> optic radiation --> occipital lobe
39
Images are projected?
upside down and reveresed right to left
40
Direct pupillary light reflex CNs
subcortical reflex arc (subconscious), afferent link is CNII and efferent link is CNIII
41
How are infant eyes different?
macula are not fully developed, poorly coordinated eye muscles, less pigmentation in iris
42
How are elderly eyes different?
Skin loses elasticity, floaters in vitreous humor, lens can't accomodate as well so vision is blurry
43
Arcus senilis
degenerative lipid material forms a grey ring around iris
44
Presbyopia
farsightedness caused by loss of elasticity of lens
45
Cataracts
lens discolors and thickens, gets cloudy
46
Glaucoma
increased intraocular pressure damages optic nerve, happens more in men
47
Macular degeneration
macula degenerates, happens more in women
48
Strabismus
Test with corneal light reflex, cross eye/lazy eye, diplopia (double vision)
49
Myopia
nearsighted
50
Hyperopia
farsighted
51
Legally blind
20/200
52
Anisocoria
pupils are different sizes
53
Entropion
Eyelashes fold in and irritate cornea
54
Nystagmus
Oscillation of eyes, can be a sign of drug use, test with 6 cardinal positions of gaze
55
bitemporal hemianopsia
optic chiasm is cut so fibers can't cross over so visual loss of temporal half of each field
56
left homonymous hemianopsia
right optic tract is cut/lesion, visual loss involves same half of each eye, in this case the right side of the retina so left temporal vision field and right nasal field are disrupted
57
AV Nicking
Arterial venous nicking, sign of hypertension, artery and vein cross in eye causing compression of vein
58
Papilledema
Inflammation of optic disc from increased intracranial pressure, disc is cloudy, usually bilateral, if untreated can lead to blindness
59
3 main facial muscles
frontalis, temporalis and masseter
60
CNVII
facial nerve, innervates frontalis, temporalis and masseter, facial expressions
61
CNV
trigeminal nerve, pain and touch of facial muscles
62
What are flat nasal labial folds a sign of?
Stroke or bells palsy
63
What are enlarged parotid glands a sign of?
mumps
64
Where are the parotid glands?
located in cheeks over mandible
65
sternoclidomastoid muscle innervation and movement
CNXI (accessory), rotation and flexion of head
66
trapezius muscle innervation and movement
CNXI (accessory), move shoulders and extend head
67
preauricular lymph nodes
in front of ears, drain scalp, forehead, ears and eyelid
68
posterior auricular nodes
behind ears, drains parietal scalp and external ear
69
occipital nodes
at the base of skull, drains parietal scalp
70
How to test CNXI?
shrug shoulders and turn head
71
what is an off center trachea the sign of?
sign of collapsed lung or tumor pushing it off center
72
what is a bruey in carotid the sign of?
artery is at least 70% occluded
73
Tonsilor nodes
at angle of jaw, drains tonsils, floor of mouth, posterior palette, thyroid gland
74
submandibular nodes
drains mucosa of mouth an dlips, tongue, conjunctiva, submaxillary glands
75
submental glands
drains tongue, floor of mouth, mucosa of mouth and lips
76
superficial cervical nodes
overlying sternoclidomastoid muscle, drains ear and skin of neck
77
posterior cervical nodes
drains thyroid, posterior scalp and posterior neck skin
78
deep cervical nodes
drains thyroid, trachea, posterior scalp and posterior neck skin
79
superclavicular nodes
closest to heart, right node drains mediastinum/lungs/esophagus, left node drains thorax and abdomen
80
thyroid gland
isthmus lies over trachea, largest endocrine gland, makes T3 and T4 hormones to regulate cellular metabolism and growth
81
acromegaly
pituitary gland makes too much growth hormone, enlarged bones
82
fetal alcohol syndrome
thin upper lip, flat nose, wide eyed
83
bell's palsy
peripheral lesion of CNVII (facial), partial facial paralysis
84
goiter
enlarged thyroid
85
how often do you need to measure infant's skull?
ages 0-6, every visit until age 2 and yearly after
86
anterior fontanel
between frontal and parietal bone, intersection of coronal and metopic sutures, closes 12-18 months, diamond shape
87
posterior fontanel
triangle shape, sagittal and lamboid sutures, between parietal and occiptial bones, closes 6 weeks - 2 months
88
what are the 3 layers of skin?
epidermis, dermis and subcutaneous
89
epidermis
stratefied squamos epithelium, avascular
90
stratum corneum
part of the epidermis, top protective barrier of keratinized cells, regulates water loss
91
stratum germinativum
deepest layer that lies closest to dermis where there is active cell generation
92
dermis
highly vascular, regulates body temperature by dilating/constricting blood vessels, contains sensory fibers and nourishes epidermis, can stretch/contract
93
subcutaneous/hyperdermis
structures/anchor, loose connective tissue and subcutaneous fat, retains heat/calories/cushion
94
eccrine sweat glands
regulates body temperature via water secretion, almost everywhere
95
apocrine sweat glands
deeper, only in axilla, nipples, anogenital area, eyelids, external ear, responds to emotions by secreting fluid with proteins, decomposes to make BO
96
sebaceous glands
secretes sebum to prevent dry hair and skin, in face and scalp but not in hands and feet
97
papilla
capillary loop at follicle that provides nourishment
98
nail is made of?
epidermal cells converted to hard plates of keratin
99
lunula
new nail growth
100
pitting in nails is a sign of?
psoriasis
101
erythema
reddening of skin in patches
102
vitiligo
loss of color in blotches
103
acanthosis nigricans
area of dark, velvety discoloration in body folds
104
mongolian spots
on babies, does not blanch when pressed on, goes away with age, blue/brown
105
cafe au lait spot
flat, pigmented birthmarks, light brown, only worry if 6 or more
106
acrocyanosis
persistent blue extremities, usually benign and goes away
107
cutis marmorata
blue/red veiny pattern when cold, worry for babies b/c they need more O2 when it is cold
108
comedonal acne
white head or black head
109
pustular acne
infected red pimple
110
seborrheic keratosis
scaly, warty, raised growths, not malignant, black or brown
111
senile lentigines
sun spots/liver spots
112
diaphoresis
excess sweat
113
edema causes?
DVT, chronic, venous insufficiency, lymphedema, orthostatic edema, congestive heart failure
114
mobility
skin's ease of rising
115
turgor
skin's ability to return to place, reflects moisture and elasticity
116
purulent
pus drainage
117
serous
yellow-clear serum
118
serosanguinous
serous + blood
119
eschar
dead tissue, contains necrotic tissue, black
120
ecchymosis
bruise
121
excoriation
scratch
122
decubitus
lying down ulcer
123
macule
primary, circumscribed, flat, nonpalpable change in skin color, up to 1 cm, ex. freckles, ptechiae
124
patch
primary, macule larger than 1 cm, ex. liver spots, mongolian spot
125
papule
primary, palpable, elevated, circumscribed, solid mass with no fluid inside, up to 1cm
126
plaque
primary, flat, elevated surface larger than 0.5cm, lots of papules together
127
nodule
primary, solid, elevated, firm or soft mass less than 1-2cm, can extend deeper into the dermis than a papule, ex. fibroma, intradermal nevi
128
tumor
primary, solid, elevated firm or soft mass larger than 1-2cm, extend deeper into dermis, can be benign or malignant
129
lipoma
primary, fatty tumor
130
hemangioma
primary, pink growth filled with blood
131
wheal
primary, superficial, raised, red, transient lesion, with somewhat irregular borders due to localized edema, fluid is held diffusely in the tissues, ex. mosquito bite
132
urticaria
primary, wheals that are super itchy, like hives
133
vesicle
primary, circumscribed, superficial, elevated cavity containing free fluid, up to 1cm, ex. herpes simplex
134
bullae
primary, larger vesicle, single chambered, superficial in epidermis, thin walled, larger than 1cm, ex. friction blister
135
cyst
primary, incapsulated fluid/pus filled cavity in dermis or subcutaneous layer, larger than 1cm, ex. sebaceous cyst
136
pustule
primary, circumscribed, superficial, elevated cavity, contains turbid fluid (pus), up to 1cm, ex. impitigo, acne
137
crust
secondary, dried residue of burst vesicle
138
scaling of tinea pedis
secondary, compact desiccated flakes of skin, dry/greasy, from shedding of dead excess keratin, visible white/silver exfoliation of dermis
139
fissures
secondary, linear crack with abrupt edges, can extend to dermis
140
erosion
secondary, superficial, circumscribed loss of epidermis, leaves scooped out shallow depression, moist but no blood, heals w/o scar, stage 2 pressure sores
141
ulcer
secondary, extends into dermis, may bleed, leaves scar
142
scar
secondary, fibrous connective tissue
143
atrophy
secondary, stretch marks, thinning epidermis leads to depressed skin level
144
lichenification
secondary, thickening/roughening of skin as a result from intense scratching, ex. eczema
145
annular
circular
146
confluent
lesions running together
147
discrete
lesion is alone
148
grouped
cluster of lesions
149
gyrate
twisted, coiled
150
target
lyme disease
151
polycyclic
circular lesions
152
zosteriform
along dermatome
153
petechiae
secondary, flat, red, pin sized macules of blood,
154
purpura
larger macule/papule of blood, 0.3-1cm, does not blanch
155
ecchymosis
1cm, non-elevated, rounded/irregular, blue/purple patch
156
cherry angioma
bright red papule, benign
157
spider angioma
legs radiating from center, disappears when pressed down, sign of liver disease
158
telangiectasia
permanently dilated vessels, can be in basal cell carcinomas/nifedi pine
159
nevus flammeus
port wine stain, present at birth, dilated dermal capillaries, pale pink to purple macules, face & trunk
160
herpes simplex I
cold sore vesicles, oral
161
herpes simplex II
genital
162
varicella
chicken pox
163
herpes zoster
shingles, on one side of body, can cause deafness/blindness/facial paralysis
164
skin cancer warning signs
ABCDEE, asymmetry, border, color, diameter, elevation, enlargement
165
basal cell carcinoma
most common, slow growing, rarely metastisized, translucent, dome-shaped papule with overlying telangiectasia
166
actinic keratosis
malignant potential, flaky patches
167
squamous cell carcinoma
invasive malignancy, can arise from actinic keratosis, heals/breaks down
168
alopecia areata
non-scarring hair loss, sharply defined area, usually immunological
169
hirsution
excessive female hairiness
170
clubbing
nails rounded, angle flattens out, can be a sign of lung disease or cancer
171
CNI
olfactory, smell
172
CNII
optic
173
CNIII
oculomotor
174
CNIV
trochlear
175
CNV
trigeminal
176
CNVI
abducens
177
CNVII
facial
178
CNVIII
vestibulocochlear
179
CNIX
glossopharyngeal
180
CNX
vagus
181
CNXI
accessory
182
CNXII
hypoglossal
183
Middle ear ossicles
malleus, incus, stapes
184
otosclerosis
abnormal bone growth in the middle ear that causes hearing loss
185
presbycusis
age-related hearing loss
186
conductive hearing loss
mechanical dysfunction of external or middle ear, can be a partial loss
187
sensorineural loss
damage to either inner ear, CNVIII or auditory cerebral cortex, can be from age or ototoxic drugs
188
What can cause vertigo or staggering gait?
inflammed labrynth of the ear
189
Tinnitus
ear ringing, associated with nerve damage
190
weber test
512 fork at midline of head, laterlizing midline is normal
191
weber test for conductive loss
lateralizes to bad ear because air doesn't influence hearing so all through the bone
192
weber test for sensorineural loss
no sound in bad ear, louder in left ear
193
Rinne test
press tuning for to mastoid process, move away until pt can't hear, move fork to outside of ear
194
rinne test for conductive loss
AC
195
rinne test for sensorineural loss
AC>BC but in a smaller ratio in the or no sound in bad ear, AC>BC in normal ratio
196
what can cause sensorineural loss
asprin, antibiotics, diuretics, aging, loud noises
197
what is pain in mastoid process a sign of?
otitis media, mastoiditis
198
tragus pain is a sign of?
otitis externa (swimmers ear)
199
What does impacted cerumen cause?
partial deafness, tinnitus, dizziness
200
exostosis
formation of new bone outcropping, seen in swimmers and surfers, can cause infections, pain, plugging, hearing loss
201
otitis externa
scaling, crusting, inflammation, discharge in external canal, painful tragus, swimmers ear
202
serous otitis media
tympanic membrane is retracted and decreased mobility, thin serous fluid
203
bacterial otitis media
red & inflammed, pus
204
perforated typmanic membrane
white scarring tightens membrane
205
most common site for nosebleeds?
Kiesselbach region
206
which sinus is not present at birth
frontal
207
which gland opens to stenson's duct
parotid
208
which gland opens to wartons duct
submandibular
209
what can cause nasal polyps
allergies
210
which gland has many openings
sublingual
211
are fordyce spots and torus palatinus normal
yes (white spots on tongue and ridge on mouth)
212
which side does the tongue deviate to (abnormal)
paralyzed side
213
what test is done for CNXII
hypoglossal, stick tongue out
214
what test is done for CNX
vagus, see that uvula rises
215
viral pharyngitis
red scratchy throat
216
bacterial pharyngitis
red scratchy throat with exudate, fever, enlarged cervical nodes, probably strep a or mono
