exam 3 Flashcards
(168 cards)
1
Q
identify midline structures of the neck from mandible to sternal notch, in order
A
Hyoid bone
thyroid cartilage
cricoid cartilage
isthmus
2
Q
palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?
A
2
3
Q
Neck pain associated with fever and headache
A
Meningitis
4
Q
ABCDEs of melanoma detection
A
Asymmetry
Border irregularity
Color
Diameter > 6 mm
Evolution of lesion over time
5
Q
Vitiligo
A
areas of no pigmentation.
6
Q
rubor
A
dependent redness from poor circulation
7
Q
brawny
A
dark leathery appearance from chronic ischemia
8
Q
Uremic frost
A
whitish coating noted with severe kidney failure.
9
Q
Wound Healing Phases
A
Inflammatory phase = 30 mins of injury; lasts 2–3 days
Proliferative phase = lasts 4 weeks; deposit collagen and growth factors, appearance of granulation
Remodeling phase = lasts 2 yrs; macrophages stimulates gradual replacement of the new collagen w mature ones
10
Q
clean wound
A
under sterile conditions and not at risk for infection
ex: incisions
11
Q
Clean-contaminated wound
A
under sterile conditions but involving the respiratory, GI, GU, genital without unusual contamination
ex: appendectomy, hysterectomy, cholecystectomy, and oropharyngeal surgeries
12
Q
Contaminated wound
A
Exposed to contents of GI tract or infected fluids from GU. ex: open, traumatic wounds (lacerations, punctures, open fractures)
13
Q
Infected wound
A
Exposed to contaminants or has evidence of infection prior to surgery.
ex: traumatic wound bc of the high risk for foreign body, bacteria, and chemical contaminant
14
Q
Braden Scale
A
scores patients from 1 to 4 in each of six subscales:
sensory perception,
moisture,
activity,
mobility,
nutrition,
friction
score of 14–18 = high risk of pressure ulcers
15
Q
Norton Scale
A
rates patients from 1 to 4 in each of five subscales:
physical condition,
mental condition,
activity,
mobility,
incontinence
score < 14 = high risk of pressure ulcers
16
Q
serous drainage
A
clear
17
Q
sanguineous drainage
A
bloody
18
Q
serosanguineous drainage
A
mixed clear & bloody
19
Q
fibrinous drainage
A
sticky yellow
20
Q
Wallace Rule of Nines
A
% of total body surface area burned in adults
all is 18% except
arms 9% each
head 9%
genital 1%
21
Q
macule
A
flat discoloration of skin <1 cm
ex: freckle
22
Q
papule
A
solid, raised <1 cm
ex: Wart, insect bite, molluscum contagiosum
23
Q
nodule
A
solid, palpable, <1 cm, often with some depth
ex: urticaria
24
Q
pustule
A
enclosed, pus filled
ex: acne, folliculitis
25
wheal
red or flesh colored, raised, circular/oval area
ex: allergic rxn, basal cell carcinoma
26
vesicle
Fluid filled, <1 cm
ex: chickenpox, shingles/herpes
27
malar rash
red macular lesions over forehead, cheeks, and chin, resembling a butterfly - lupus
28
Sjögren syndrome
Autoimmune disease where moisture-producing glands are affected, resulting in a dry mouth and dry eyes
29
Raynaud phenomenon
Poor perfusion
diff colored fingers
30
Trichotillomania
compulsive hair pulling
31
Patch
flat discoloration > 1 cm
ex: vitiligo, melasma, tinea versicolor
32
Plaque
raised > 1 cm
ex: Psoriasis, lichen sclerosus
33
Bulla
Fluid filled, >1 cm
ex: Partial-thickness burns, bullous impetigo
34
Lichenification
resembling tree bark, caused by excessive scratching or rubbing
35
Excoriation
Lesion from scrape
scratching or rubbing
ex: cat scratches
36
Annular
Ringlike, circular
37
Umbilicated
Central depression
ex: Herpes zoster, basal cell carcinoma
38
Filiform
Papilla-like or fingerlike projections
ex: warts
39
Verruciform
Circumscribed, papular with rough surface
ex: wart
40
Diffuse
Distributed widely across affected area without any pattern
41
Confluent
With enlargement or multiplication, begins to coalesce to form larger lesion
42
Discrete
Single, separated, well-defined borders
ex: melanoma, wart
43
Satellite
Single lesion(s) in close proximity to larger lesion, as if “orbiting”
ex: cutaneous candidiasis
44
Zosteriform
Distributed along dermatome
ex: herpes zoster
45
Impetigo
contagious skin infection from Staph
vesicles / bullae that rupture and ooze serous fluid, forms honey-colored crust.
46
Tinea Versicolor
caused by normal skin flora results in hypopigmented patchy lesions generally distributed on the upper chest and back, and proximal extremities.
47
Psoriasis
chronic skin disorder
reddish pink lesions covered with silvery scales.
48
Actinic Keratosis
solar keratosis,
from UV damage.
macular / papular lesions are discrete, with rough, scaly surface.
49
Basal Cell Carcinoma
nodular / papular lesion
shiny w rolled pearly border;
telangiectasias (spider veins)
grows slowly and rarely metastasize
50
Squamous Cell Carcinoma
related to actinic keratosis / sun exposure. Lesions are papular, nodular, or plaque
51
Hemangioma
vascular lesions, present at birth, rapidly develop and grow but resolve by age 9 years
Made up of endothelial cells that fill with blood, blanch with applied pressure
52
Purpura
Purplish macules or papules result from bleeding under the skin secondary to inadequate clotting mechanisms.
53
Avulsion
Trauma forces the skin to separate from underlying structures, leaving an open ragged wound.
54
Stage 1. Pressure injury:
non-blanchable erythema of intact skin
55
Stage 2. Pressure injury
partial-thickness skin loss with exposed dermis, moist
56
Stage 3 Pressure injury
full-thickness skin loss
adipose (fat) is visible
granulation tissue and epibole (rolled wound edges)
Undermining and tunneling may occur.
57
Stage 4. Pressure injury
exposed / directly palpable fascia, muscle, tendon, ligament, cartilage, or bone
58
Unstageable pressure injury
extent of tissue damage cant be confirmed bc it's obscured by slough or eschar.
59
Deep tissue pressure injury
persistent non-blanchable deep red, maroon, or purple discoloration
Intact or nonintact skin
dark wound bed / blood-filled blister.
60
Neuropathic Ulcer
Loss of sensation in an extremity impairs the patient’s ability to detect pressure on the feet. Sustained pressure or friction results in lost skin surface
seen in DM
61
Venous Ulcers (Vascular)
Venous ulcers develop from chronic pooling of blood in the extremity
62
Wagner Classification of Ulcers
0 = Pre-ulcerative lesion, healed ulcers, presence of bony deformity
1 = Superficial ulcer
2 = Penetration thru subQ tissue (exposes bone, tendon, ligament, or joint)
3 = Osteitis, abscess, or osteomyelitis
4 = Gangrene of forefoot
5 = Gangrene of entire foot
63
functions of the skin
largest organ of the body;
first line of defense
temperature maintenance,
fluid and electrolyte balance,
absorption, excretion,
sensation,
immunity,
vitamin D synthesis
64
Flexion
decrease angle - brings bones together
65
Dorsiflexion
toes move toward the head
66
Plantar flexion
toes move away from the head
67
Extension
increase angle to a straight line
68
Hyperextension
Extension beyond the neutral position
69
Abduction
away from the center of the body
70
Adduction
toward the center of the body
71
Rotation
Turning joint around a longitudinal axis
72
Internal rotation
Rotating an extremity medially
73
External rotation
Rotating an extremity laterally
74
pronation
palm down, on tummy
75
Supination
palm up, lie on back
76
Circumduction
circular motion that combines flexion, extension, abduction, and adduction
77
Inversion
sole of the foot inward
78
Eversion
sole of the foot outward
79
Protraction
forward and parallel to the ground
80
Retraction
backward and parallel to the ground
81
Opposition
thumb touch the little finger
82
Hyperthyroidism
hi T3, T4
low TSH
hi energy (nervous, tremors)
heat intolerance
hi sweat (smooth skin)
hi appetite
hi metabolism (wt. loss)
exophthalmos (bulging eyes)
hi BM (diarrhea)
hi vitals (BP, HR)
*Goiter
83
Hypothyroidism
low T3, T4
hi TSH
low energy (depressed, fatigue)
cold intolerance
low sweat (dry, brittle skin)
low hair (hair loss)
low appetite
low metabolism (wt. gain)
low BM (constipation)
*Myxedema
84
Atony
Lack of normal muscle tone or strength
85
Hypotonicity
Diminished muscle tone
86
Spasticity
Hypertonic, so the muscles are stiff and movements awkward
87
Spasm
Sudden violent involuntary muscle contraction
88
Fasciculation
Involuntary muscle twitching
89
Tremors
Involuntary muscle contraction
90
RATING SCALE FOR MUSCLE STRENGTH
5/5 (100%) = Normal ROM against gravity and full resistance
4/5 (75%) = Good ROM against gravity and moderate resistance
3/5 (50%) = Fair ROM against gravity
2/5 (25%) = Poor ROM w joint supported; cant perform against gravity
1/5 (10%) = Trace Muscle contraction, but no movement of joint
0/5 (0%) = No visible muscle contraction
91
Phalen Test
Evaluates for carpal tunnel
patient to flex the wrists 90 degrees and hold the backs of the hands to each other for 60 seconds.
Positive = numbness, burning, or pain
92
Tinel Sign/Test
Evaluates for carpal tunnel
Percuss lightly over the median nerve located on the inner wrist.
Pain, numbness, or tingling is a positive (abnormal)
93
“Empty Can” Test
Tests supraspinatus impingement.
abduct the shoulder to 90 degrees, flex to 30 degrees and point thumbs down. place resistance as the patient lifts up.
Pain or weakness suggests tendinopathy or tear.
94
Bulge Test
Differentiates soft-tissue swelling from excess fluid in knee
patient supine, milk upward along the knee 2-4x. Then press on the lateral side of the knee and check for bulging.
A bulge = mild joint effusion
95
Ballottement/Suprapatellar Pouch Effusion
Evaluates presence of large fluid in knee
patient supine and knee extended, press on the quadriceps muscle above knee w one hand and keep that pressure there
Palpate the patella with the other hand.
If fluid = patella will rebound / ballot against fingers.
96
Drawer Sign
Checks for knee injury
supine patient flex knee to R angle. grasp the leg just below the knee and see whether you can move it toward and away from yourself.
positive = head of tibia moves > half an inch from joint. This test may also be used for ankle injuries.
97
loculation test
Evaluates for loculated fluid IN KNEE.
hyperextend knee by placing one hand superior to patella and other posterior to heel.
More than 2 or 3 cm hyperextension is abnormal.
98
McMurray Test
Checks for meniscus cartilage injury.
patient supine, flex hip and knee. Support knee w one hand and hold foot w other, rotating foot laterally. Slowly extend patient’s knee while assessing for the positive findings of pain / clicking.
99
Lachman Test
Checks for knee laxity.
Flex knee 20–30 degrees then pull tibia anteriorly.
An injured ACL = increased movement forward (positive sign)
100
Thomas Test
Assesses presence of flexion contracture of hip
supine patient extend one leg and flex hip and knee of the other, bring knee to the chest.
A flexion contracture of the hip will cause the extended leg to rise up off the table.
101
Patrick / FABERE Test
Tests for sacroiliac / hip joint as source of pain.
patient supine and place foot of involved side on opposite knee.
Inguinal pain = pathology in hip joint / surrounding muscles
Extend ROM by placing one hand on flexed knee and other hand on anterior superior iliac spine of opposite side. Press down on each points.
complains of increased pain posteriorly = injury in sacroiliac joint
102
Lasegue Test (Straight Leg Raising)
Checks for herniation of lumbar disk and nerve irritation / pressure.
patient supine and both legs extended, support and raise one leg.
pain is a positive sign.
103
Trendelenburg Test
Assesses for hip disease w muscle weakness
Observe from behind. Ask patient to stand on one foot, then the other. pelvis should remain level horizontally.
abnormal / positive = the other hip drops when the patient stands on the weak side.
104
Morse Fall Scale
1. History of falling; immediate or within 3 mo
No = 0
Yes = 25
2. Secondary dx
No = 0
Yes = 15
3. Ambulatory aid
nurse = 0
Crutches, cane, walker = 15
Furniture = 30
4. IV/heparin lock
No = 0
Yes = 20
5. Gait/transferring
Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20
6. Mental status
Oriented to own ability = 0
Forgets limitations = 15
No risk = 0–24
Low risk = 25–50 (standard fall prevention interventions)
High risk ≥ 51 (high-risk fall prevention interventions)
105
gait: Antalgic
walks with a limp to avoid pain
short stance phase.
106
gait: Ataxic
unsteady, uncoordinated walking with a wide base, feet thrown out, and a tendency to fall to one side.
107
gait: Short leg
limps with walking unless wearing adaptive shoes.
108
Footdrop / steppage gait
lifts the advancing leg high so that the toes may clear the ground
places sole of the foot on floor before the heels
109
Apraxic gait
difficulty initiating walking
slow and shuffling
110
Trendelenburg gait
trunk lists toward the affected side when wt bearing is on that side
waddling if both hips affected
111
Rheumatoid arthritis
chronic inflammatory disease of joints
causes thickening of synovial membrane, veins engorged
Fibrosis follows, w bony ankylosis.
ulnar deviation
worse in AM
stiff, heat, red, swelling, pain w motion
112
Osteoarthritis
local, progressive, noninflammatory disease results in deterioration of articular cartilage and bone
worse in PM and rainy weather
early AM stiffness
swelling, hard bony nodules > 2-3 mm, pain with motion
113
Fibromyalgia
stiffness, especially in the morning
Sleep disturbance
no swelling but tender
114
Rotator Cuff Tear
hunched shoulder and limited arm abduction
positive drop arm test
115
Osteoporosis
bone resorption is faster than deposition
weakened bone increases risk for fractures
post menopause
116
Genu Valgum
knock knee
117
Ganglion Cyst
soft, nontender, round nodule on the wrist that becomes more prominent during flexion. benign
118
Bursitis (Olecranon Bursitis)
bursae in the body cushion and lube joints, tendons, and ligaments.
Bursitis is inflammation of the bursa, due to injury, infection, or RA.
119
Epicondylitis
inflammation of the lateral epicondyle of elbow
pain radiates down extensor surface and increases with resisting extension of the hand
Inflammation of the medial epicondyle (golf elbow) is rare
from excessive wrist flexion and pronation.
120
Swan Neck and Boutonnière Deformity
fingers have “swan neck” appearance from flexion contracture of the metacarpophalangeal joint
chronic RA, ulnar deviation
121
Congenital Hip Dislocation
femur is displaced from the acetabulum
asymmetrical gluteal crease, uneven limb length, and limited abduction when the thighs are flexed.
positive Barlow–Ortolani sign = newborn
positive Trendelenburg sign = older kids
122
Polydactyly
congenital deformity results in extra fingers or toes
123
Herniated Nucleus Pulposus
intervertebral disks slip out of position bc trauma / strain.
Rupture of nucleus pulposus (soft inner portion) puts pressure on spinal nerve root.
sciatic pain radiating down the leg, numbness
straight leg raise = sciatic pain
124
syndactyly
congenital deformity of webbed fingers,
125
Talipes Equinovarus (“Club Foot”)
foot turned to the side, and the involved leg is smaller and shorter than the normal side.
126
Dupuytren contracture
can't extend ring and lil fingers
Hyperplasia of the palmar fascia causes painless flexion contracture of the digits, impairing function.
127
Ulnar Deviation
Stretching of the articular capsule and muscle imbalance
fingers to point in the ulnar direction.
128
Ankylosing Spondylitis
chronic, progressive inflammation of the spine and sacroiliac
bony growths.
129
Heberden and Bouchard Nodes
Hard, nontender bony growths on the distal (Heberden) and proximal (Bouchard) interphalangeal joints.
deviation of the fingers.
130
Carpal Tunnel Syndrome
occurs from repetitive motion
burning, pain, and numbness
positive Phalen test or Tinel sign
131
scoliosis
lateral curve of spine, usually affecting both thoracic and lumbar parts, w deviation in one direction in thoracic spine and the other direction in lumbar spine
structural = caused by spinal defect
functional = caused by habits
132
synovial / diarthrotic joints
freely moveable
most common
ball & socket
133
Kyphosis
a forward bending of the upper thoracic spine
134
Lordosis
an exaggerated curve in the lumbar spine
common in late pregnancy and obesity.
135
cauda equina syndrome
surgical emergency
include progressive motor / sensory deficit, saddle anesthesia, sciatica, and bowel / bladder incontinence
136
fibrous / synarthrotic
immovable
ex: skull sutures
137
cartilaginous / amphiarthrotic
slightly moveable
ex: costal cartilage, symphysis pubis
138
ball and socket
hip, shoulder
139
hinge
elbow, knee
140
pivot
atlas, axis
141
condyloid
wrist
142
saddle
thumb
143
gliding
intravertebral
144
hallux valgus
bunions on feet
genetic
145
CN XI
cant shrug shoulers
146
temporal arteritis
temporal artery hard, thick, tender
inflam leading to blindness
147
herniated disc
flat lumbar curve
148
musculoskeletal function
* supports the body
* Protects internal organs
* Mobility
* RBC production
* Store minerals
149
joints
functional unit of the msk system bc they permit mobility needed for ADLs
150
special considerations: musculoskeletal: pregnant
*center of gravity changes, increased risk for falls.
*should not lift heavier than 9 kg (20 lb) and should use good body mechanics doing it.
*Backaches from lumbar lordosis and poor back support
*Increased wt from fetus and breast, strains ABD muscles
*teach pelvic tilts to strengthen ABD muscles
* increased relaxin loosens cartilage btwn pelvic bones → “waddling” gait
151
Chadwick sign
blue discoloration of the vaginal wall and cervix
sign of pregnancy
152
special considerations: musculoskeletal: newborns
*single transverse palmar crease = Down syndrome or normal inherited fam trait.
*Ortolani and Barlow maneuvers to check for hip dislocation.
153
Ortolani Maneuver.
infant supine. With baby’s legs together, flex knees and hips 90 degrees. Then, with your middle fingers over the greater trochanters and thumbs on the inner thighs, abduct the hips while applying upward pressure
154
Barlow Maneuver
After Ortolani maneuver. Maintain hold at 90 degrees flexion; apply downward pressure while adducting the hips
155
special considerations: musculoskeletal: kids / teens
*Evaluation for scoliosis begins when child can stand, but is a focused exam prior to and during puberty.
156
special considerations: musculoskeletal: elderly
*Limited abduction of shoulder addressed asap to prevent “frozen shoulder,” a condition that occurs during / after a hospital stay.
*Contractures of the hips and knees are abnormal but common in pts who use wheelchairs.
*small, short, stepped gait that gradually becomes normal = Parkinson disease.
*wide-based gait w a heel-to-toe foot slap to floor = cerebellar disorder
*gait when the leg doesn't swing thru smoothly, catches on the floor, drags, or stops next to the other foot = cerebrovascular disease.
157
Epidermis
Protective waterproof layer of keratin
nonvascular
Regenerates easily and quickly
Melanocytes —eumelanin and pheomelanin— skin color
Merkel cells- light sensation
158
Dermis
papillary- capillaries, blood vessels, nerve endings.
connects directly to the epidermis, exchange of O2, nutrients, and waste
reticular- made of collagen and elastin
159
Subcutaneous
Anchors the skin layers to underlying tissues
insulation, skin's mobility, store calories, cushions
160
skin function
protection
temp regulation
psychosocial (appearance)
sensation
makes Vit D
absorption
elimination (sweat)
immunologic (when broken)
161
Diabetic neuropathy
high sugar
affects sensation
162
Aquathermia
water therapy
too moist delays healing
163
hair function
*Protection
* Insulation
* sensory stimulation to nervous system
* gender identification
made by hair follicules
164
Sudoriferous glands
makes sweat to maintain body temp
eccrine = sweat
apocrine = body odor
165
Lanugo
fine downy hair of newborn
166
Vernix caseosa
thick, cheesy substance in newborn
167
Acrocyanosis
temporary bluish discoloration of the hands, feet, and face due to immature CV system, cold, or crying spells
168
Chloasma
Discoloration changes on face
“mask of pregnancy"
