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Health Assessment
General Assessment, skin, and nails
45
Nursing
Undergraduate 2
09/29/2009

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Cards

Term
Describe the meaning of the following percussion sounds... resonance, dullness, tympany, flatness, hyperresonance
Definition
resonance = air filled, dullness = solid, tympany = hollow, flatness = dense, hyperresonance = too much air
Term
What makes of the percussion tones?
Definition
pitch, intensity, duration, quality
Term
What is a general survey?
Definition
first few moments of contact with the patient (first overall impression)
Term
What do you observe in a general survey?
Definition
body structure, mobility, behavior, physical appearance
Term
What is it important to know when observing a client in a general survey?
Definition
the norms (to have something to compare it to)
Term
What are life span considerations during a general survey?
Definition
development, culture, lifespan
Term
What are anthropometric measurements?
Definition
a method of measuring the human body and assessing nutritional status as well as growth and development
Term
When are you considered overweight? obese?
Definition
overweight > 10% ideal body weight; obese >20% ideal body weight
Term
What are normal colors of skin?
Definition
pink/white-ruddy pink, yellow-olive, ivory-deep brown, brown-black, blue-black
Term
What abnormal colors of skin?
Definition
pallor, jaundice, cyanosis, erythema
Term
What is pallor?
Definition
paleness due to decreased skin to oxygen
Term
What is cyanosis?
Definition
blue skin (usually starts at toes)
Term
What is erythema?
Definition
redness of the skin usually due to CO poisening
Term
What is jaundice?
Definition
orange color (usually indicates liver problems)
Term
What do you inspect/palpate on the skin?
Definition
color, texture, thickness, moisture, mobility/turgor, temperature, intactness/presence or absence of lesions
Term
macule
Definition
1- color change, flat, circumscribed, less than 1 cm (ex: freckle)
Term
patch
Definition
macules larger than 1 cm (ex: measles)
Term
papule
Definition
solid, elevated, circumscribe, less than 1 cm (ex: wart/mole)
Term
plaque
Definition
coalased papules (surface elevation greater than 1 cm) (ex: psoriasis)
Term
nodule
Definition
solid, elevated hard or soft, larger than 1 cm, may extend deeper into dermis than papule (ex: RA, looks encapsulated and well-defined)
Term
tumor
Definition
larger than a few cm in diameter, firm or soft, deep into dermis, encapsulated
Term
wheal
Definition
superficial, raised, transient, erythematous, irregular shape (ex. mosquito bite)
Term
pustule
Definition
circumscribed, elevated, pus filled cavity (ex: acne)
Term
cyst
Definition
encapsulated, fluid-filled cavity, skin tensely elevated, in dermis or subq layer (in moister areas)
Term
vesicle
Definition
elevated cavity up to 1 cm, clear fluid, superficial (ex: chicken pox, small blisters)
Term
bulla
Definition
larger than 1 cm, elevated cavity, clear fluid, superficial (ex: big blister)
Term
crust
Definition
secondary lesion - thickened, fried out exudates of vesicles/pustules (ex: scab)
Term
excoriation
Definition
superficial abrasion, sometimes crusted, scratches from intense itching (often self inflicted)
Term
fissure
Definition
linear crack down into dermis
Term
scale
Definition
compact, flakes of skin from shedding excess keratin cells
Term
ulcer
Definition
deeper depression in dermis, irregular shape (area of reddened tissue surrounds it)
Term
scar
Definition
connective tissue that replaces normal tissue when skin lesion is repaired
Term
petechia
Definition
tiny hemmorages (less than 2 mm), round, discrete, dark red/purple/brown
Term
purpura
Definition
confluent (run together) petechia
Term
ecchymosis
Definition
"bruise" - large patch of capillary bleeding into tissue
Term
hematoma
Definition
elevated bruise (enough bleeding into tissue to elevate skin)
Term
venus star
Definition
blood vessel difficulties (spider angioma, hemangioma)
Term
spider angioma
Definition
fiery, red, star-shaped, with solid circular center
Term
hemangioma
Definition
raised red/bluish area of blood vessels
Term
alopecia
Definition
baldness (occurs almost always from hair curlers)
Term
ABC's of malignant melanoma
Definition
asymmetrical, border irregularity, color, diameter > 6mm, elevation/enlargement
Term
What is a lesion of the nail bed? what does it indicate?
Definition
pigment bands; melanoma (normal in darker skinned people though)
Term
normal angle of nails? abnormal?
Definition
160 or less; 180 or more
Term
what does clubbing of nails indicate?
Definition
CVD
Term
what does unevenness of toenails indicate?
Definition
poor circulation
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