Skin, Hair, Nails, Head, Neck, and Eye Assessment Flashcards
(43 cards)
made under sterile conditions
and at very low to no risk for
infection. Usually skin or vascular
incisions
Clean wounds
made under sterile conditions but involving the
respiratory, GI, genital, urinary tract without unusual contamination.
Clean-contaminated wound
exposed to content of GIT or infected fluids from GUT
Contaminated wound
exposed to contaminants or
exhibiting evidence of infection prior to surgery.
Infected wound
*No inflammation
*No break in sterile technique
*Wound primarily closed/Not drained
*Aero- digestive, genitourinary & Biliary tract not entered
*Potential infection rate
Clean Wounds
*Traumatic Wounds
*Acute inflammation present
*Major break in sterile technique
*Gross spillage/contamination from respiratory, gastrointestinal, biliary, or genitourinary tracts
*Potential infection rate 15%-20%
Contaminated wounds
*No inflammation
*Minor break in sterile technique
*Aerodigestive or genitourinary tract entered without spillage
*Potential infection rate 8%-10%
Clean-contaminated wound
*Old Traumatic wounds
*Clinical infection present
*Perforated Viscus
*40% expected infection rate
*Devitalized tissue
Class IV Wounds (dirty) or Infected Wounds
an abnormal collection
of CSF in the ventricles of the brain causing enlargement of the cranium. (separation of cranial sutures, bulging fontanels and dilated veins across the scalp)
HYDROCEPHALUS
developmental delays and congenital abnormalities are associated with maternal intake of alcohol during pregnancy. (microcepahly, flattened
check bones and upper lip, small eyes)
FETAL ALCOHOL SYNDROME (FAS)
results from either extra chromosomes 21 or translocation of chromosomes 14 or 15 with 21 or 22. (microcephaly, flattened occipital bones, slanted small eyes,
depressed nasal bridge low set ears and protruding tongue).
DOWN SYNDROME (Trisomy 21)
due to diet deficient in iodine. (puffy facial features and often a larger than normal tongue.
CONGENITAL HYPOTHYROIDISM
premature closure
and ossification of the fontanels result in cranial deformities and microcephaly.
CRANIOSYNOSTOSIS
congenital or acquired contraction of the sternocleidomastoid muscle causing the head to inclined to one side. (ROM is decreased)
TORTICOLLIS
overproduction of growth
hormones resulting to thickening of the skin, subcutaneous tissue and facial bones and coarsening of facial features
ACROMEGALY
paralysis usually unilateral of
the facial nerve (CN VII) can be transient or permanent. Common causes include trauma, compression and infection.
BELLS PALSY
excessive
production of exogenous ACTH results in a round “moon” facies, fat deposits at the nape of the neck, “buffalo hump”, and sometimes a velvety discoloration around the neck (acanthosis nigricans).
CUSHING SYNDROME
a degenerative
neurological disease which presents a masklike facial appearance, rigid muscles,
diminished reflexes and a shuffling gait.
PARKINSON DISEASE
or brain attack.
Embolism, hemorrhage, or vasospasm in the brain results in ischemia of surrounding tissue and neurological damage. Symptoms depend on the part of the brain affected
CVA/STROKE
hardening of the skin usually noted in the hands and face. Skin becomes firm and loses mobility seemingly fixed to underlying tissues
SCLERODERMA
enlarged thyroid gland
(hyper/hypothyroidism)
GOITER
severe hypothyroidism, presents periorbital swelling and edema of the face, hands, and feet.
MYXEDEMA
Assessment of Visual Acuity
● Distance Vision
● Near Vision
● Color Vision
the patient reads the letter 20 ft. away
Snellen test
