Term
What is Health Assessment (5)?
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Definition
Data Collection
Formulation of a Data Base
Starting Point for Diagnostic/clinical reasoning
Starting Point for Nursing Process
Starting Point for Action |
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Term
| The collection of subjective and objective data about a patient's health |
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Definition
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Term
| data that consists of information provided by the affected individual |
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Definition
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Term
| data that includes information obtained by the health care provider through physical assessment, the patient's record, and laboratory studies |
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Definition
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Term
| the totality of information available about the patient |
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Definition
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Term
| the purpose of assessment |
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Definition
| to make a judgement or diagnosis |
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Term
| the process of analyzing health data and drawing conclusions to identify diagnosis. |
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Definition
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Term
| what are the 4 parts of diagnostic reasoning? |
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Definition
1. Attending to initially available cues
2. Formulating diagnostic hypotheses
3. Gathering data relative to tentative hypotheses
4. evaluating each hypothesis with new data collected--> final diagnosis |
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Term
| what are the 6 phases of the nursing process? |
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Definition
1. assessment
2. diagnosis
(-outcome identification)
3.planning
4. implementation
5. evaluation
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Term
| the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgement. |
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Definition
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Term
| First-level priority problems... |
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Definition
emergent, life-threatening, immediate
ex: establishing an airway, supporting breathing |
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Term
| Second-level priority problems... |
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Definition
| next in urgency, require prompt intervention to prevent deterioration, may include mental status change or acute pain |
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Term
| Third-level priority problems... |
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Definition
important to the patient's health but can be addressed after more urgent problems
ex: lack of knowledge, family coping |
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Term
| a systematic approach to practice that uses the best evidence, clinician's experience, and patient's preferences and values to make decisions about care and treatment |
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Definition
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Term
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Definition
| includes a complete health history and full physical examination |
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Term
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Definition
| used for a limited or short-term problem. more targeted to a specific problem |
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Term
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Definition
| evaluates the status of any identified problem at regular intervals to follow up on short-term or chronic problems |
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Term
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Definition
| rapid collection of data, which commonly occurs while performing lifesaving measures. |
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Term
| views health as the absence of disease |
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Definition
| biomedical model of western medicine |
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Term
| views the mind, body, and spirit as interdependent and functioning as a whole within the environment. |
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Definition
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Term
| a structured interaction between you and a patient. |
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Definition
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Term
| the exchange of information so that each person clearly understands the other |
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Definition
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Term
| what YOU bring to the interview |
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Definition
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Term
| 3 internal factors promote good communication: |
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Definition
liking other
expressing empathy
having the ability to listen |
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Term
relate mainly to the physical setting in an interview
ex: quiet room, ensuring privacy, preventing interruptions |
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Definition
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Term
| What are the phases of the nurse-patient Relationship |
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Definition
Pre-Interactional
Introduction
Working phase
Closing/Termination |
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Term
| The phase of the nurse-patient relationship where you look at charts, review labs, and receive report about patient |
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Definition
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Term
| The phase of the nurse-patient relationship that starts with conversation. Were both forming opinions about the other |
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Definition
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Term
| The phase of the nurse-patient relationship involving interventions, teaching, and planning |
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Definition
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Term
| The phase of the nurse-patient relationship involving referrals, summary of accomplishments, and plans for follow-up |
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Definition
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Term
| What are some nonverbal tools/signs? |
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Definition
physical appearance
posture
gestures
facial expression
eye contact
voice
touch |
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Term
What are 10 traps of interviewing?
(Fucking Under An Awning Doesn't Put Love There, I Wish) |
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Definition
1. false assurance/reassurance
2. unwanted advice
3. authority
4. avoidance language
5. distancing
6. professional jargon
7. leading/biased questions
8. talking too much
9. interrupting
10. "why" questions |
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Term
when taking a health history, what 8 categories do you gather data in?
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Definition
biographic data (name, address, DOB, etc)
source (patient, parent)
reason for seeking care (chief complaint)
present health/history of present illness (PQRSTU)
past health (illnesses, hospitilizations, allergies)
family history
review of systems
functional assessment (ADLs, relationships, habits,) |
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Term
| When taking present health/history of present illness (HPI), for completing a symptom analysis, what do you look for? |
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Definition
location
character/quality
quantity or severity
timing-onset, duration, frequency
setting
aggravating/relieving-what makes it worse? better?
associated
patient's perception |
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Term
| What acronym is helpful when analyzing symptoms as part of present health/hisory of present illness? |
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Definition
P- Provocative/Palliative (what makes it better)
Q- Quality/Quantity
R- Region, Radiation
S- Severity
T- Timing
U- Understand, Perception |
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Term
| a person's emotional and cognitive function |
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Definition
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Term
| significant behavioral or psychiatric patterns associated with stress or disability |
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Definition
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Term
| What are some examples of organic mental disorders? |
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Definition
demenita
delirium
liver disease
brain disease |
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Term
| what are some examples of psychiatric mental disorders? |
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Definition
no detectable organic etiology
-mental illness: schizophrenia, bipolar disorder, ocd |
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Term
| What are the 4 main components of the mental status assessment? explain. |
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Definition
Appearance- observe patient posture, body movements, dress, grooming and hygiene
Behavior- evaluate level of consciousness, facial expression, speech, mood, and affect
Cognition- check orientation, attention span, recent memory, remote memory, and new learning
Thought Process- evaluate thought processes, thought content, and perceptions. Also screen for anxiety, depression, and suicidal thoughts |
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Term
| a simplified scored assessment of cognitive function. brief assessment of memory, orientation to time and place, naming, reading, copying, or visual-spatial orientation, writing, and following 3-stage demand. |
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Definition
| Mini-Mental State Examination |
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Term
| When do you perform a mental status examination? |
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Definition
behavior changes
changes in orientation
altered mental status
brain lesions
aphasia
symptoms of psychiatric mental illness
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Term
| for A&OX3, what does the X3 represent? |
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Definition
Person-do they know who they are
Place-do they know where they are
Time-do they know what day, month, year it is |
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Term
| What are the levels of consciousness? Explain. |
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Definition
Alert:Fully aware of external and internal stimuli.
Lethargic:Drifts off to sleep when not stimulated.
Obtunded: Sleeping most of the time, difficult to arouse
Stupor/semicoma: Responds only to persistent or vigorous shake or pain
Coma:No response to pain, ranges from “light coma” with some reflex action to “deep coma” which includes no motor activity.
Delirium (acute confusional state): Disturbance of consciousness or cognition that is acute in onset. (Caused by medications, etc.)
Dementia: non reversible |
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Term
| As part of the general survey, what do you observe about the patient during the interview? |
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Definition
Physical Appearance
Facial Features
Body Structure
Mobility (Gait, ROM)
Behavior |
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Term
| What do you cover in an acute care general survey? |
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Definition
| age, ethnicity, gender, mental status, orientation, appears stated age?, level of distress, development, nourishment, dress |
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Term
| What types of data are there? |
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Definition
physical
cognitive
psychosocial
behavioral
environmental
developmental |
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Term
| Your overall impression of the patient; begins when you first encounter him/her. |
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Definition
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Term
| What is a medical diagnosis? |
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Definition
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Term
| What is a nursing diagnosis? |
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Definition
| individual's response to disease or risk |
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Term
| What are the 4 assessment techniques (vital signs)? |
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Definition
Inspection
Palpation
Percussion
Auscultation |
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Term
Close, careful observation of the patient as a whole body and then of each body system.
This assesment technique you:
compare bilaterally
need good lighting
adequate exposure
use of specifics
look for abnormalities |
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Definition
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Term
This type of assessment uses touch to assess:
texture
temperature
moisture
organ location/size
swelling
vibration/pulsation
rigidity/spasticity
crepitation
lumps/masses
tenderness or pain on palpation |
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Definition
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Term
Type of assessment using tapping of patient's skin with short, sharp strokes to create sounds. Used to assess:
location
size
density of organ
abnormal mass
deep tendon reflex |
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Definition
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Term
| Type of assessment: Listening to sounds made by the body using a stethescope. |
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Definition
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Term
| What are some influences on temperature? |
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Definition
diurnal cycle
menstrual cycle
exercise
age |
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Term
| What are some routes of non-invasive temperature measurement? explain. |
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Definition
oral-accurate and convenient. not for comatose
axillary- under the armpit
rectal- used when other routes aren't practical
tympanic- quick and efficient
temporal- not used often |
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Term
| What is a normal temperature? |
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Definition
98.6 degrees F
37 degress C |
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Term
| What is the normal Pulse rate for adults? For infants? what is it called if lower than normal minimum? higher than maximum? |
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Definition
Normal for adults 50-90
Normal for infacts 100-160
Lower then 50 Bradycardia
Higher than 90 Tachycardia |
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Term
| What are some developmental considerations for Respirations? |
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Definition
Rate
Depth
Symmetry
Effort
Normal are relaxed, regular, automatic, silent
4:1 (pulse:respirations) |
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Term
| What three qulities are assessed when taking a pulse? |
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Definition
Rate- normally 50-90 BPM
Rhythm- normal=even, regular tempo
Force- shows strength of heart stroke volume |
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Term
| pressure of the blood against the blood vessel walls |
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Definition
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Term
| The maximum pressure felt on the artery during left ventricular contraction (or systole) |
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Definition
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Term
| the elastic recoil (or resting) pressure the blood exerts constantly between contractions |
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Definition
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Term
| The difference between the systolic and diastolic pressures and reflects the stroke volume. |
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Definition
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Term
| The pressure forcing blood into the tissues, averaged over the cardiac output |
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Definition
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Term
| What is the average blood pressure in a young adult? |
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Definition
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Term
| What are some influences on blood pressure? |
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Definition
Age
Race
Weight
Emotions
Gender
Diurnal rhythm
Exercise
Stress
Medications
Smoking/diet |
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Term
| What are the 5 physiologic factors controlling blood pressure? |
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Definition
Cardiac output
Peripheral vascular resistance
Blood volume
Blood viscosity
Vessel wall elasticity |
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Term
| A cuff that is too narrow yields what kind of a blood pressure? |
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Definition
| falsely high blood pressure |
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Term
| a cuff that is falsely wide yields what kind of a blood pressure |
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Definition
| falsely low blood pressure |
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Term
| an unpleasant sensory and emotional experience associated with actual or potential tissue damage |
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Definition
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Term
| Is pain objective or subjective? |
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Definition
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Term
| In terms of neuronatomy, this is a highly complex and subjective experience that originates from the central or peripheral nervous system or both |
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Definition
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Term
| Pain that originates from larger internal organs, such as kidneys, stomach, ntestines, gallbladder, and pancreas. |
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Definition
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Term
| Pain that comes from sources such as blood vessels, joints, tendons, muslces, and bone. Injury may result from pressure, trauma, or ischemia |
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Definition
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Term
| Pain that is derived from the skin and subcutaneous tissue. The injury is superficial, with a sharp, burning sensation. |
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Definition
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Term
| Pain that is felt at a particular site but originates from another location. |
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Definition
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Term
| Type of pain that is short term, self-limiting, follows a predictable trajectory, and dissipates after injury heals |
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Definition
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Term
This type of pain continues for 6 months or longer and can last for years. Types are malignant and nonmalignant. results from abnormal processing by pain fibers. does not stop when injury heals
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Definition
| Persistent or Chronic Pain |
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Term
| Pain before next dose of analgesic is due |
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Definition
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Term
| What are some acute pain behaviors? |
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Definition
Guarding
Grimacing
Moaning
Agitation, restlessness
Stillness
Diaphoresis
Change is VS |
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Term
| What are some chronic pain behaviors? |
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Definition
Bracing
Rubbing
sighing
diminished activity
change in appetite
being with other people
movement
exercise
prayer
sleeping |
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Term
| The body's largest organ system |
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Definition
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Term
| What are the 3 layers of skin? Explain. |
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Definition
Epidermis- thin, outer highly differentiated layer, basal cell layer, dead keratinized cells
Dermis- innter supportive layer; C.T. or collagen, Nerves, blood vessels, lymphatics, elastic tissue
Subcutaneous- adipose tissue |
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Term
| What is included in epidermal appendages? |
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Definition
| hair (vellus, terminal), sebaceous and sweat glands (eccrine, apocrine), nails |
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Term
| what gland is sweat for thermoregulation? |
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Definition
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Term
| what gland releases odor, pheremones? |
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Definition
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Term
| What gland is important for fluid balance and thermoregulation? |
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Definition
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Term
| what glands lubricate skin and decrease water loss? |
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Definition
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Term
| What are some structure/functions of the skin? |
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Definition
protection
prevents penetration
waterproof
slows infection
perception-sensory
temperature regulation
identification
communication (blushing)
wound repair
absorption and excretion
Vitamin D production |
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Term
| What are some developmental considerations for newborns? |
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Definition
Lanugo hair- fine downy hair all over
Vernix Caseosa-thick whitish mix of sebum & shed epithelial cells
Mongolian Spots
skin is more permeable
Thermoregulation is limited
As child grows: thickens, darkens, toughens, more lubricated |
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Term
| What are some developmental considerations for adolescents? |
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Definition
apocrine glands secrete
sebaceous glands more active
SQ fat deposits increase
secondary sex characteristics: areola diameter, breast tissue, pubic hair, axillary hair, facial hair (male) |
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Term
| What are some developmental considerations for Pregant women? |
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Definition
increased pigment in areola and nipples, vulve, midline of abdomen (linea nigra), face (chloasma)
stretch marks related to fragile C.T.
sweat and sebaceous increase secretion
fat deposits in hips and buttocks |
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Term
| What are some developmental considerations in the aging adult? |
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Definition
decreased elasticity
thinner skin
decreased sebaceous production: dry
decreased response for thermoregulation
Fragile blood vessels: bruising (senile purpura)
sun exposure: more wrinkling, decreased elasticity, lesions
loss of protective SQ layer
Hair: grays, thins
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Term
| What are some skin conditions noted to be specific to black patients? |
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Definition
keloids
pigmentary disorders
pseudofolliculitis
melasma |
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Term
| What are melanoma stats r/t whites/blacks and whites/hispanics |
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Definition
Melanoma:
20X higher in whites than blacks
4X higher in whites than hispanics |
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Term
| What are some color changes affecting skin? |
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Definition
Pallor (vasoconstriction-C.T. shows through, pale)
Erythema (red)
Cyanosis (blue)
Jaundice (yellow) |
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Term
| Fluid accumulation in intercellular space |
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Definition
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Term
| What is the scale for testing Edema? |
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Definition
1+: mild: slight indentation, no perceptible swelling of extremity
2+: moderate: indentation subsides rapidly
3+: deep: indentation remains for a short time, extremity looks swollen
4+: very deep: indentation lasts a long time, extremity is very swollen |
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Term
| To assess the skin, what do you look at? |
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Definition
temperature
moisture
texture
thickness
edema
mobility
turgor
vascularity/bruising
lesions |
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Term
| When inspecting and palpating the hair/scalp, what do you look for? |
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Definition
color
texture
distribution (vellus/terminal, developmental, ischemia)
Lesions
Insects |
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Term
| When inspecting and palpating the nails, what do you look for? |
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Definition
shape and contour (diamond assessing for clubbing)
consistency
color
capillary refill (color return in under 3 seconds)
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Term
| For Skin self-exam, what rule do we use? explain. |
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Definition
ABCDE
A- asymmetry
B- border
C- color
D- diameter
E- elevation/enlargement |
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Term
| What are confluent Lesions? |
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Definition
Lesions that run together
[image] |
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Term
| What are discrete lesions? |
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Definition
Distinct, individual, separate
ex: acne
[image] |
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Term
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Definition
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Term
| What are grouped Lesions? |
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Definition
clustered together, contact dermatitis
ex: poison ivy
[image]
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Term
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Definition
straight line, stripe, lacerations
ex: Scratches |
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Term
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Definition
Concentric rings
ex: Lyme disease |
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Term
| What are Zosteriform Lesions? |
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Definition
Linear, arranged along nerve route
ex: Herpes Zoster, Shingles
[image] |
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Term
| What are Polycyclic lesions? |
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Definition
Annular lesions that grow together
ex: Psoriasis
[image] |
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Term
| What are some PRIMARY lesions? |
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Definition
macules
papules
patches
plaques
nodules
wheals
tumors
urticaria
vesicles
cysts
bullas
pustules |
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Term
| What are some characteristics of a Macule? |
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Definition
Flat
change in color
<1 cm
ex: freckle, flat nevi |
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Term
| What are some characteristics of a Patch? |
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Definition
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Term
What are some characteristics of a Papule?
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Definition
Raise
Solid
<1 cm
elevated Nevus
ex: wart |
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Term
| What are some characteristics of a Plaque? |
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Definition
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Term
| What are some characteristics of a Nodule? |
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Definition
solid
elevated
>1 cm
may extend into dermis |
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Term
| What are some characteristics of a Wheal? |
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Definition
superficial
raised
erythemous
irregular
transient
ex: mosquito bite |
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Term
| What are some characteristics of a Vesicle? |
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Definition
elevated, cavity filled
< 1 cm
Blister
Herpes Simplex
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Term
| What are some characteristics of a Bulla? |
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Definition
Vesicle > 1 cm
single chambered
burns
friction blisters |
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Term
| What are some characteristics of a Cyst? |
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Definition
encapsulated
fluid-filled
In dermis or SQ
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Term
| What are some characteristics of a Pustule? |
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Definition
cavity filled with Pus
Impetigo
Acne |
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Term
| What are some characteristics of a Keloid? |
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Definition
hypertrophic scar
elevated, invasive |
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Term
| What are some common skin lesions? |
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Definition
primary contact dermatitis
allergic drug reaction
tinea corporis (ringworm)
labial herpes simplex (cold sores)
herpes zoster (shingles)
psoriasis |
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Term
| What are some abnormal conditions of the hair and scalp? |
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Definition
Sebhorric Dermatitis
Alopecia Areata
Traumatic Alopecia
Traction Alopecia |
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Term
| What are some abnormal nail conditions? |
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Definition
Paronychia
Late Clubbing
Onycholysis |
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Term
What are the stages of Pressure Ulcers? Explain.
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Definition
Stage I- Skin and layers intact; non-blanching erythema; heals with pressure relief
Stage II- interruption of skin layer; serum-filled blister; shallow, popped blister; epidermis in base
Stage III- Deeper crater; into SQ tissue, adipose tissue
Stage IV- through fascia into muscle, bone
Unstageable- base of wound is obscured by dead tissue; blood filled blister
DTI- Deep Tissue Injury; skin intact; deep bruising |
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Term
| What are some characteristics of Vascular Arterial Ulcers? |
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Definition
tips of toes, between toes
wound skin tight, hard, shiny, hairless, cool, atrophic
claudicaton (walking pain)
pedal pulse absent
round, smooth edges
little odor or drainage
NEVER elevate |
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Term
| What are some characteristics of Vascular Venous Ulcers? |
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Definition
in shin, ankle
irregular edges
extensive drainage
edema
no claudication
ALWAYS elevate |
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Term
| what are some characteristics of diabetic ulcers? |
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Definition
mixed etiology
sole, ball of foot, metatarsal heads
poor prognosis r/t disease, loss of sensation
painless or burning
most frequent reason for diabetic hospitilization |
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Term
A patient who is admitted for liver failure would be likely to show what skin changes?
a. cyanosis
b. flushing
c. rubor
d. jaundice |
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Definition
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Term
When taing the health history, the patient complains or pruritus. what is a common cause of this symptom?
a. excessive bruising
b. hyperpigmentation
c. cancer
d. drug reactions |
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Definition
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Term
A flat macular hemorrhage is called
a. purpura
b. ecchymosis
c. petechiae
d. hemangioma |
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Definition
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