Term
| Chest/Lung assessment: IPPA |
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Definition
Inspect
Palpate
Percuss
Auscultate |
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Term
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Definition
P - Palliative or Provocative (is there anything that makes the pain better or anything that makes it worse?)
Q - Quality - patient's description of the pain
R - Region and Radiation
Severity scale
Time
U "what do you think is causing that headache" |
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Term
| Neuropathic pain: what is it, what is unique about it and at what level does it occur. |
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Definition
Abnormal processing of pain message
Most difficult type of pain to assess & treat
Neurochemical level |
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Term
| Pain transmission: what is the pathway and the name of the tract |
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Definition
Nociceptor ---> Dorsal horn ---> crosses midline ----> Thalamus/Limbic/cortex
Anterolateral Spinothalamic Tract |
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Term
| Visceral, Deep somatic, cutaneous, referred pain definitions |
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Definition
Visceral pain – from injury or stretching of organs, accompanied by autonomic responses (vomiting, nausea, pallor, diaphoresis)
e.g. appendicitis, cholycystitis
Deep somatic pain - from blood vessels, joints, tendons, muscles & bone
Injury may result from pressure, trauma, or ischemia
Cutaneous pain - from skin surface & subcutaneous tissues
injury is superficial, with a sharp, burning sensation.
Referred pain - felt at a particular site but originates from another location. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin |
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Term
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Definition
Acute pain
Short term
Self-limiting
Follows a predictable trajectory
Dissipates after injury heals
Persistent pain
Continues for 6 months or longer
Types are malignant (cancer-related) and nonmalignant
Does not stop when injury heals |
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Term
| Pain assessment questions (for reference, probably not test material) |
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Definition
Questions to ask:
Where is your pain?
When did your pain start?
What does your pain feel like?
How much pain do you have now?
What makes the pain better or worse?
How does pain limit your function/activities?
How do you behave when you are in pain? How would others know you are in pain?
What does pain mean to you?
Why do you think you are having pain? |
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Term
| Integumentary Assessment: what is it part of, what will be incorporate it into? |
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Definition
Part of “head to toe” assessment
Separated to discuss & focus on components
You will incorporate into “regional” assessment
i.e. head & neck, extremities, torso (front & back) |
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Term
| What should be in the back of your mind when doing integument assessment? |
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Definition
| communicable diseases, alleries |
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Term
| Functions of the skin: Protects against? What does it regulate/synthesize? What does it sore and excrete? What does it allow? |
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Definition
Largest organ in body, provides unique ID
e.g. fingerprints
Protects against heat, UV rays, trauma, infection, loss of H20 & electrolytes
Regulates temperature, synthesizes Vitamin D
Repairs surface wounds
Stores blood and fats
Excretes metabolic wastes
Allows sensing of world
touch, pressure, temperature, pain |
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Term
| Skin anatomy and physiology |
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Definition
skin composed of 2 layers
epidermis – outermost layer, 5 strata (layers)
dermis – layer of connective tissue embedded with hair follicles, sweat glands, oil glands, & sensory receptors
new skin cells are formed in basal layer
in epidermis, strata above dermis
consist of a fibrous protein called keratin
melanocytes (in epidermis) produce skin pigment: melanin
subcutaneous tissue stores ~ 50% body’s fat cells
sweat glands: eccrine & apocrine
apocrine glands found in axillary and anogenital regions
sebaceous glands produce sebum, usually released in hair follicles
hair: thin fiber compound of dead keratinized cells
hair distribution varies in different parts of the body
Vellus hair – pale, short strands over most of body
Terminal hair – darker, found in scalp & eyebrows, axillary region, pubic region, legs of adults, & male face & chest
nails are thin plates of keratinized epidermal cells, covering distal ends of fingers & toes |
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Term
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Definition
| Smooth, thin, and flexible |
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Term
| Good places to pick up jaundice |
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Definition
| soles of feet or palms of hand, palate, eyes |
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Term
| Integumentary system special considerations for aging: elasticity, sebum production, perspiration, melanin, nails |
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Definition
skin elasticity decreases
sebum production decreases, causes dryness
amount of perspiration decreases
decrease in melanin production
resulting in graying hair & increased light sensitivity
nails thicker, more brittle |
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Term
| Other factors affecting skin, hair and nail health |
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Definition
stress
may exacerbate skin conditions
visible skin disorders may contribute to problems with self-esteem & body image
culture, socioeconomic status, & environment
changes in skin color may be difficult to evaluate in people with dark skin.
nurse inspects lips, oral mucosa, sclera, palms of hands, & conjunctiva to detect color changes |
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Term
| Color variations in skin - pallor: possible causes, central vs peripheral |
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Definition
Loss of color in skin due to absence of oxygenated Hgb
Widespread; most apparent in face, mouth, conjunctivae, & nails
Possible causes: anemia, shock (decreased perfusion, vasoconstriction), local arterial insufficiency |
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Term
| Color variations: absence of colour: causes and names of two specific examples |
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Definition
Absence of Color
Congenital or acquired loss of
melanin pigment
Congenital loss typically
generalized (albinism), acquired loss typically patchy (vitiligo) |
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Term
| Color variations in the skin - cyanosis: characteristics, cause, where most apparent |
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Definition
Mottled blue color in skin due to
inadequate tissue perfusion with
oxygenated blood
Most apparent in nails, lips, oral
mucosa, tongue. |
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Term
| Color Variations: uremia and brown |
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Definition
Uremia:
grey or orange-green due to retention of urinary chromogens in blood
generalized, if perceptible
Brown:
Increase in production and deposit of melanin
generalized or localized |
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Term
| COlor variations - erythema: definition, generalized vs localized, examples of when it's normal. |
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Definition
Redness of skin due to increased visibility of normal oxyhemoglobin
Generalized, or on face & upper chest, or localized to area of inflammation or exposure
Can be normal
e.g. during exercise, “blushing” |
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Term
| Color Variations: Jaundice definition where most apparent first |
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Definition
Yellow undertone due to increased
bilirubin in blood
Generalized, most apparent in
conjunctivae & mucous
membranes first |
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Term
| Color variations - Carotenemia description, cause, where most apparent |
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Definition
Yellow-orange tinge caused by
increased levels of carotene in the
blood & skin
Most apparent in face, palms of
hands, soles of feet |
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Term
| Abnormal findings - skin, types of lesions |
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Definition
primary lesions
secondary lesions
vascular lesions
infections
malignant lesions |
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Term
| Lesion configurations: annular, confluent, discrete, grouped, gyrate, target, linear, polycyclic, zosteriform |
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Definition
Annular - ring worm
Confluent - rubella
Discrete - moles
Grouped - Herpes simplex
Gyrate - coiled or twisted
Target - like a target
Linear - scratches
Polycyclic - urticaria (hives)
zosteriform - herpes zoster (shingles) |
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Term
| Primary lesions - definitions, bunch of examples |
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Definition
develop on previously unaltered skin
macule/patch
Papule/plaque
Nodule
Vesicle/bulla
Tumour, Cyst
Pustule
Urticaria (hives)
Wheal - transient, circumscribed, raised, erythematous
See text p. 251-252 |
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Term
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Definition
circumscribed, elevated, solid lesion,
< 1 cm
Plaque: >1cm |
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Term
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Definition
small, superficial, circumscribed skin elevation, < 0.5 cm, containing serous fluid
Bulla > 0.5 cm |
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Term
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Definition
small (< 1 cm), circumscribed, superficial elevation, filled with purulent material
also described as a vesicle filled with pus |
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Term
| Secondary lesions - how formed and a bunch of examples |
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Definition
result of a change in a primary lesion
Excoriation
Atrophy
Erosion
Lichenification
Scales – debris on surface
Crust – debris on surface
Ulcer
Fissure
Scar
Keloid |
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Term
| Vascular lesions - how caused and a bunch of examples |
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Definition
result of changes in vessel integrity
Hemangioma
Port-wine stain
Spider angioma
Venous lake
Ecchymosis
Hematoma
See Jarvis text 256-257 |
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Term
| Purpuric lesions - Petechiae |
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Definition
Petechiae
Pinpoint (1-3 mm), flat, round, discrete, dark red, purple or brown spots under the skin surface caused by bleeding from superficial capillaries, will not blanch (intradermal hemorrhages)
Difficult to see in darker skin, best seen in areas of lighter melanization
Abdomen, buttocks, volar surface of forearm |
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Term
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Definition
Purpura
Flat, red to purple
Irregularly shaped
(>3 mm)
Extensive patches
Caused by:
Bleeding disorders
thrombocytopenia
Scurvy
Capillary fragility in elderly |
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Term
| Infections/inflammatory skin lesions |
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Definition
Measles (rubeola, rubella)
Varicella (chicken pox)
Tinea pedis (athlete’s foot)
Psoriasis, Eczema, Dermatitis
Herpes (simplex “cold sore”, zoster – shingles)
Impetigo |
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Term
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Definition
basal cell carcinoma
squamous cell carcinomas
Kaposi’s sarcoma
malignant melanoma |
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Term
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Definition
Asymmetry
Borders
Colour
Diameter (no more than 6mm)
Elevation |
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Term
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Definition
seborrhea
tinea capitis
alopecia areata
infection of hair follicles
folliculitis - bacterial or fungal infection of follicle
furuncles - large “boil”
hirsutism
excess body hair in females |
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Term
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Definition
Chronic inflammatory skin disease due to overgrowth of yeast
Most often on scalp or face
More commonly in males
“Dandruff” shampoo, selsun blue
Lather mustache, eyebrows |
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Term
| Folliculitis and Furuncles |
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Definition
| Infected hair follicle.... furuncle also called boil. |
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Term
| Nail abnormalities: splinter hemmorhage, onycholysis, clubbing, paronychia, spoon nails |
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Definition
splinter hemorrhage
Red brown linear streaks
Usually caused by minor trauma
onycholysis
Loosening & lifting of nail plate
Cause: fungal infection, iron deficiency
clubbing
Result of decreased oxygenation
paronychia
Inflammation in nail folds
spoon nails
Usually congenital
May be iron deficiency anemia |
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