Exam 2 Flashcards by Lindsay Cabalo

CN I

Olfactory
- smell

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CN II

Optic
- sight

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CN III

Oculomotor
- eyeball movement: MR, IR, SR, IO
- movement of upper eyelid: LP
- pupillary light reflex

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CN IV

Trochlear
- eyeball movement: superior oblique

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CN V

Trigeminal
- Opthalmic: facial sensation/pupillary dilation
- Maxillary: facial sensation
- Mandibular: chewing/facial sensation

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CN VI

Abducens (6 Abs)
- eyeball movement: lateral rectus

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CN VII

Facial
- taste: anterior of tongue
- facial expression/eyelid closing
- lacrimation
- salivation

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CN VIII

Vestibulocochlear
- hearing: cochlea
- balance: vestibular apparatus

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CN IX

Glossopharyngeal
- sensation from posterior 1/3 of tongue, tonsils middle ear, pharynx
- stylopharyngeus muscle
- salivation

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CN X

Vagus
- swallowing
- elevation of palate
- talking
- coughing
- gag reflex
- heart rate
- GI peristalsis
- sweating
- vasovagal synope
- peripheral chemoceptors

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CN XI

Accessory
- head turning: SCM
- shrugging: trapezius

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CN XII

Hypoglossal
- most muscles of tongue (except palataglasus)
- tongue movement

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What to look at when assessing integumentary system?

skin
hair
scalp
nails

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Integumentary Assessment Equipment

penlight
gloves
flexible ruler/tape measure
gown/drape to cover the client

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What are you looking for when inspecting the skin?

color
odor
integrity

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Abnormal findings in skin:

tenderness may indicate….

inflammation

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Abnormal findings in skin:

increase moisture

fever or thyroxitoxicosis

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Abnormal findings in skin:

decrease moisture

dehydration, myxedema, chronic nepriritis

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Abnormal findings in skin:

coarse, thick, dry skin

hypothyroidism

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Abnormal findings in skin:

skin more fine-texture

hyperthyroidism

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Abnormal findings in skin:

smooth, thin, shiny skin

Arterial Insufficiency

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Abnormal findings in skin:

thick, rough skin

venous insufficiency

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Abnormal findings in skin:

decreased turgor/tenting

dehydration or normal aging

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Abnormal findings in skin:

increase turgor/tension

scleroderma and edema

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What are you looking for when inspecting the nails?

color condition angle of attachment presence of focal or generalized abnormalities (ridges/clubbing)

Normal nail angle

160*

abnormal nail angle

> or = 180*

Abnormal findings in nails: yellow nails

cigarette smoking fungal infection psoriasis

Abnormal findings in nails: very distal band of reddish-pink or brown covering <20%

cirrhosis disorder causing hypoalbuminemia

Abnormal findings in nails: distal band of reddish-pink or brown covering 20% to 60% of the nail

renal disease hypoalbuminemia

Abnormal findings in nails: green nails (pseudonomas)

infection

Abnormal findings in nails: white nails (leukonychia)

trauma liver cardiovascular renal disease

Abnormal findings in nails: black nails

trauma

Abnormal findings in nails: splinter hemmorhage

bacterial endocarditis trauma

Abnormal findings in nails: clubbing

congenital heart disease cystic fibrosis chronic pulmonary disease

Abnormal findings in nails: spooning/concave nail (koilonychia)

severe iron deficiency anemia

Abnormal findings in nails: separation of nail from the bed (onycholysis)

fungal infection psoriasis eczema following trauma as allergic response to new products

Abnormal findings in nails: pitting

psoriasis

What to look for when examining lesions?

size color shape consistency elevation location distribution configuration tenderness fluid drainage

arise from healthy skin tissue

primary lesion

non-palpable skin color change < 1cm freckles, mole melanoma

Macule

palpable circuscribed solid elevation of the skin <1cm elevated nevus psoriasis

Papule

palpable circumscribed deep firm 1-2cm wart

Nodule

serous fluid-filled <1cm blister, herpes simplex, varicella

Vesicle

pus-filled varied in size acne

Pustule

solid mass deep larger than 1-2cm epithelioma

Tumor

palpable irregular borders edematous insect bite

Wheal

thinning of the skin w/loss of the skin furrow skin is shiny and translucent arterial insufficiency

Atrophy

results from change in primary lesion

secondary lesion

lost epidermis moist surface no bleeding ruptured vesicle

Erosion

dried blood serum pus scab

Crust

flakes of skin that exfoliate dandruff, psoriasis, eczema

Scale

linear crack tinea pedis

Fissure

loss of epidermis and dermis with possible bleeding and scarring pressure ulcer, venous stasis ulcer

Ulcer

can appear under the fingernails, on the palms and soles of the feet more common amongst african descent

Melanoma

results from aging changes or blood vessel damage in or near the skin

Vascular lesions

red center radiating with red legs. up to 2cm, possibly raised

Spider Angioma

red, 1-2cm, round, possibly raised

Cherry Angioma

bluish, spider shaped or linear, up to several inches in size

Spider Vein

deep reddish purple, flat

Petechiae (1-3mm) Purpura (larger than 3mm)

purple fading to green or yellow over time, varies in size, flat

Ecchymosis

raised ecchymosis

Hematoma

have not yet broken through skin

stage 1 pressure ulcers

have a break in the top 2 layers of skin

stage 2 pressure ulcers

affect the top 2 layers of skin as well as fatty tissue

stage 3 pressure ulcers

are deep wounds that may impact muscle, tendons, ligaments, and bone

stage 4 pressure ulcers

diaper dermatitis intertrigo impetigo atopic dermatitis (eczema)

examples of skin lesions in CHILDREN

primary contact dermatitis tinea pedis (ringworm of the foot) psoriasis labial herpes simplex (cold sores)

examples of skin lesions in ADULTS

lentigines (liver spots) seborrheic keratosis dermatosis papulosa nigra (tag-like lesions) acrochordons (skin tags) sebaceous hyperplasia

examples of skin lesions in OLDER ADULTS

AVPU Scale

A = Alert V = Verbal stimulus response P = Pain stimulus response U = Unresponsive

assigns points according to the client's degree of alertness and response to verbal and painful stimulation

AVPU Scale

Hypertrophic scarring caused by excess collage formation

Keloids

coin or oval-shaped nummular eczema

round/oval

lesions that remain separate and apart common to many skin disorders moles

discrete

lesions that are grouped or clustered herpes simplex

grouped

lesions that run together or are confluent common in childhood disease rubella

confluent

lesions arranged in lines are common with contact dermatitis resulting from poison ivy or herpes zoster

linear

ring-shaped lesions may be ringworm

annular/circular

lesions arranged in partial rings, or arcs, occur in syphilis

arciform

a bull's eye lesion, or round lesion with central clearing typical of erythema multiforme and lyme disease

iris

meshlike pattern as in lichen planus

reticular

lesions have serpentine configuration as in gyrate erythema

gyrate

coalesced, concentric circles, such as in urticaria

polycyclic

lesions distributed over entire body such as urticaria from allergic reactions hives, varicella (chicken pox)

diffuse/generalized

lesions that are sparsely distributed seborrheic keratosis (non-cancerous, benign skin growth)

scattered

lesions in a very limited, discrete area location may indicate contact w/allergen or wheal from insect bite

localized

confined to a specific body area tinea capitis (fungal infection) pityriasis rosea (skin rash)

regional (head, torso)

psoriasis

extensor surfaces

intertrigo

flexor surfaces

herpez zoster (shingles)

dermatone

herpes simplex virus type 2 pediculosis pubis

dermatome (hairy areas)

contact dermatitis diaper rash intertrigo (erythema and scaling of body folds)

intertriginous areas

actinic keratosis

sun-exposed areas

indications of PALLOR

anemia shock lack of blood flow

indications of CYANOSIS

hypoxia impaired venous return

indications of JAUNDICE

liver dysfunction red blood-cell destruction

indications of ERYTHEMA

inflammation localized vasodilation sun exposure rash elevated body temperature

accumulation of fluid in the tissues most often from direct trauma or impaired venous return

Edema

trace, 2mm, rapid skin response

pitting edema 1+

mild, 4mm, 10-15 sec skin response

pitting edema 2+

moderate, 6mm, prolonged skin response

pitting edema 3+

Crossed eye

Strabismus

Dancing eyes Twitching eyes or flutter during field vision test

Nystagmus

Bulging eyes

Exophthalmos

Expected findings of neck

Muscles of the neck symmetric Shoulders equal in height and with average muscle mass ROM: Flexion Lateral flexion Hyperextendion

How to maintain skin integrity

Adequate nutrition and hydration Keep clean skin and dry Apply moisturizer if prescribed

Exam 2 Flashcards

(106 cards)