Exam 1 Flashcards by Chloe Derks

complete assessment

admission
yields first diagnosis
est. database

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focused or problem centered assessment

one body system or problem

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emergency assessment

rapid collection

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follow up assessment

regular or appropriate intervals

ex. nursing home evals

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comprehensive history

biog data (name and date of birth)
health and illness patterns
request for care
present health status / problems

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request for care (includes)

what patient is there for

date of last exam

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symptom analysis

PQRSTU
provocative/palliative
quality/quantity
location
region/radiation
severity
timing
understanding/perception

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functional assessment

health percep/ management
expectations of provider
concerns for own health
hygiene

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palpation types

light 1-2 cm
temp and moisture
deep >2 cm
organs and masses

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percussion purpose

determine density, location and size, tenderness

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percussion depth

3-5 cm

*limited in high fat areas

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tympany tone

abdom/stomach

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resonance tone

lungs

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dullness tone

liver, heart or fluid

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flatness tone

bone or lrg muscle

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hyperresonanace tone and example condition

not normal!
excess air
COPD

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auscultation digraphmn use

high pitched/ bowel sounds

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auscultation bell use

low pitched

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skin cancer signs ABCD

asymm
uneven borders
1+ colors
diameter 
      lrger than 6 mm or 1/4 in (pencil eraser)

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pallor

white color

dec circulation or shock

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erythema

red color

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cyanosis

blue color

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hematoma

collection of blood (goose egg)

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contusion

bruise

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normal findings for skin

good turgor, dry, fair, warm

normal findings for nails

no clubbing, cap refill > 2-3 seconds, no white spots

norma findings for hair

texture, equal distribution, color

macule

< 1cm flat

papule

<1 cm elevated

bulla

> 1 cm fluid filled

patch

>1 cm flat

Plaque

> 1cm elevated

vesicle

< 1 cm fluid

pustule

any size w/ purulent drainage

wheal

raised any size, usually allergic rxn

scar types

keloid- raised | atrophic- bellow dermis

lichenificaiton

thickening of skin, scaly

components braden scale

``` sens. percep moisture act. mobility nutrit. friction and shearing ```

normal ear findings- outer

no lesions, edema, redness, pain and skin is intact

normal ear alignment

10 degrees vertically | equal with eye occipital line

purpose of otoscope

look at inner canal and tympanic mem | tilt head opposite side, pull ear back and up > 3 yrs

light reflections for ear otoscope

R- 5 oclock | L- 7 oclock

otitis media

middle ear infection | tympan mem red and inflammed

infant eustachian tube

horizontal, prone to ear infections

conductive hearing loss

outer/ middle | prevention sound waves

sensioneural hearing loss

inner ear | loud noise damage or ODOTOXINS

whisper test tests what

high pitch sound

accomodation

lens alteration to focus on close objects

scotoma

blind spot in visual field

epiphora

excessive eye tearing

cn nerve for vision

snellen chart

distance vision myopia (nearsightedness) need correction if 20/30 or worse

near vision

hyperopia | 14/14 normal

presbyopia

40 yrs old | dec. accommodation (lens stiffens)

confrontation test

checking inf. sup. nasal and temporal | *peripheral vision

EOM

cn 3, 4 and 6 positions of gaze (nystagmus) corneal light reflex (strabismus) cover and uncover

strabismus

eyes dont look at same point

injections

blood vessels

corneal blink reflex- cn?

cn 5 and 7 | should be unconcious

PERLA

``` pupil equal round reactive to light accommodate ```

opthalmoscope

looking for red reflex | can see optic disk or macula lutea

cranial nerve 3 4 and 6

eom (eyes)

cn 2

vision, distance and near

cn 5

facial sensations (temporal motor control)

cn 7

facial expression

cn 8

ears

cn 9-10

gag reflux and phonation (uvula and soft pal)

cn 11

neck and shoulder mvmnt

cn 12

tongue control

nomocephalic

normal skull measure from frontal to occipital prominence no tenderness birth - 2 yrs

normal trachea

midline

normal thyroid

no palpable, or tender

cn 5

facial sensations 1 branch- opthalmic 2- maxillary 3- mandibular

lymphadenopathy

enlarged nodes | due to allergies, infections or growth/ mass

patency

unobstructed, open

cn 1

smell

stetsons duct

opposite 2nd molar in inner cheek

whartons duct

underneath tongue on e/ side (ventral)

sublingual gland

along base tongue

teeth for adult inc wisdom

xerostomia

dry mouth

tonsil rating

0-4+ 0- not visible 4+ touching ex. 2+/ 0-4+

cn 3

constriction of pupils

Exam 1 Flashcards

(83 cards)