NSG-316 Exam 1

HIPAA was enacted in

1996

Jaundice

A yellowish skin color indicates rising amounts of bilirubin in the blood. Jaundice occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn Check for jaundice from eyes (sclera), skin, palms of hands, nails

where do you find pallor in dark skinned people

Ashen grey skin; pale palms, buccal mucosa, gums and conjunctival mucosa

Transduction

Noxious stimuli

Hirsutism

Shaggy or excessive hair

Nonverbal behaviors of pain

a. Acute - guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs b. Chronic - people with chronic pain typically give little indication that they are in pain are therefore at higher risk for under detection. Behaviors including bracing, rubbing, diminished activity, sighing, and change of appetite

Cutaneous pain

a. Derived from skin surface and subcutaneous tissues b. Pain is often described as superficial, sharp, or burning

Nociceptive pain

a. Develops when function and intact nerve fibers in the periphery and the CNS are stimulated b. Is triggered by events outside the nervous system from actual or potential tissue damage c. Nociception can be divided into four phases: transduction, transmission, perception, and modulation

Referred pain

a. Pain that is felt at a particular site but originates form another location. b. May originate form visceral or somatic structures

Stage III Pressure Ulcer

full-thickness skin loss - PI extends into subcutaneous tissue and resembles a crater. see subcutaneous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon

Grouped

grouped clusters of lesions ex. contact dermatitis

Health History components

• Biographic data - name, address, phone number, age, DOB, birthplace, gender, relationship status, race, ethnic origin, and occupation • Source of self - who is giving the information • Reason for seeking care • Present health of history of present illness • Past history • Medication reconciliation • Family history • Review of systems • Functional assessment or ADLs

Spirituality assessment

• FICA - faith, importance/influence, community, and address/action • F - "do you consider yourself spiritual or religious? Do you have spiritual beliefs, values, or practices that help you cope with stress?" • I - "what importance does your faith or belief have in your life? Have your beliefs influenced you in how you handle stress? Do you have specific beliefs that influence your health care decisions? If so, are you willing to share those with your health care team?" • C - "are you part of a spiritual or religious community? If so, how does this group support you? Is there a group of people you really love or who are important to you?" • A - "how should I address these issues in your health care?"

Health promotion and disease prevention

• Guidelines to prevention emphasize the link between health and personal behavior. • Disease prevention can be achieved through counseling from primary care providers designed to change people's unhealthy behaviors related to smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries, and STI's. • Health promotion is a set of positive acts that we can take.

Complete (total health) database

• Includes complete health history and full physical examination. • Describes the current and past health state and forms a baseline against which all future changes can be measured. • Yields the first diagnosis. • Collected in a primary care setting, independent, group, or private practice

Steps to Cultural Competency

• Involves understanding your own culture and health • Being culturally sensitive, appropriate, and competent.

Functional Assessments

• Measures a person's self-care ability in areas of general physical health.

Ten Traps of Interviewing

• Providing false assurance of reassurance o Ex. "don't worry. I'm sure you and your baby will be fine" • Giving unwanted advice o Ex. "If I were you..." • Using authority o Ex. "your doctor/nurse knows best" • Using avoidance language o Ex. "passed on" or "has gone to a better place" • Distancing o Ex. There is a lump in the left breast" (use your) • Using professional jargon o Make sure to use vocabulary that your patient will understand • Using leading or biased questions o "you don't smoke do you?" or "you done ever have unprotected sex, correct?" • Talking too much o Listen more than you talk • Interrupting • Using "why" questions o Ex. "why did you take so much medication" or "why did you wait so long before coming to the hospital if you were having chest pain?"

Stages of Bruising

1) Pink and red - immediately after a blow, such as banging your shin on a step or your arm on the door; area is swollen and tender to touch 2) Blue and dark purple - within a day or so of impact; caused by both low oxygen supplies and swelling at the bruising site 3) Pale green - around the sixth day → sign of hemoglobin breaking down; also means the healing process has begun 4) Yellow and brown - seventh day from the time of injury → last stage of your body's re-absorption process; bruise won't change color again, it will gradually fade away 5) Brown to disappearing

Pallor

An unhealthy pale appearance When the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly white. Pallor is common in acute high-stress states such as anxiety or fear because of the powerful peripheral vasoconstriction from sympathetic nervous system stimulation. The skin also looks pale with vasoconstriction from exposure to cold and from cigarette smoking and in the presence of edema.

Abnormal nail findings

Brittle, ridged, or spoon-shaped (kiolonychia) -> iron deficiency; splinter hemorrhages -> vitamin C deficiency; clubbing -> heart or respiratory problems

Brown-Tan

Bronzed appearance; an "eternal tan," most apparent around nipples, perineum, genitalia, and pressure points (inner thighs, buttocks, elbow, axillae) An example would be Addison disease—Cortisol deficiency stimulates increased melanin production

Secondary Lesions

Crust Scale Fissure Erosion Ulcer Excoriation Scar Atrophic scar Lichenification Keloid

Seborrhea

Dry, flaky skin on the scalp (dandruff)

Edema - definition and scale

Edema - fluid accumulating in the interstitial space; it is not present normally. To check for edema, imprint your thumbs firmly for 3-4 seconds against the ankle malleolus or the tibia If pressure leaves dent on the skin → "pitting" edema Masks normal skin color and obscures pathologic conditions such as jaundice or cyanosis bc fluid lies between the surface and the pigmented and vascular layers Scale: 1+ → mild, slight indentation, no perceptible swelling 2+ → moderate, indentation subsides rapidly 3+ → deep, indentation remains for short time, appears swollen 4+ → very deep, indentation lasts long time, appears very swollen

Vesicles

Elevated cavity containing free fluid, up to 1 cm; a "blister". Clear serum flows if wall is ruptured. Ex. herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis.

Tumor

Elevated, solid lesion, treated than 2 cm in diameter

Edema

Excessive fluid accumulation within the interstitial spaces

ABCDE

Helps identify early signs of melanoma A: asymmetry B: border - Scalping, ragged edges C: color - areas of brown, tan, white, red D: diameter - greeted than 6 cm E: elevation and enlargement

Skin turgor

How - sign of fluid loss Why - diarrhea and vomiting Normal - skin snaps rapidly back to its normal position Abnormal - poor turgor or "tenting" indicates dehydration especially combined with delayed capillary refill and tachypnea. Also occurs with malnutrition. Skin with poor turgor takes time to return to its normal position

Capillary refill

How - with the index or middle fingertip at heart level, depress the nail edge at least 5 seconds to blanch and then release Why - indicates the status of the peripheral circulation Normal - normally color returns instantly or within a few seconds in a cold environment. A healthy color return takes 1-2 seconds Abnormal - cyanotic nail beds or sluggish color return; consider cardiovascular or respiratory dysfunction, septic shock

IPPA

Inspection Palpation Percussion Auscultation

Erythema

Intense redness of the skin is from excess blood in the dilated superficial capillaries. This sign is expected with fever, local inflammation, or emotional reactions such as blushing in vascular flush areas (cheeks, neck, and upper chest). occurs with polycythemia

Tinia Capitus

Involves the scalp causing scaling, pruritus, and balding areas

Keloids

Irregularly shaped, elevated scar

C.A.G.E.

Is a questionnaire which can indicate potential problems with alcohol abuse 1) have you ever felt you needed to Cut down on your drinking 2) have people Annoyed you by criticizing your drinking 3) Have you ever felt Guilty about drinking 4) Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover

Tumors

Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although "tumor" implies "cancer" to most people ex. lipoma, hemangioma

Alopecia

Loss of hair from pulling and yanking or by other traumatic means from genetics or cancer treatment (chemotherapy)

Primary lesions

Macules Papules Patches Plaques Nodules Wheals Tumors Urticaria Vesicles Cysts Bullas Pustules

How to assess skin lesions

Note the color, elevation (flat, raised, or pedunculated), pattern or shape (grouping or distinctiveness of each lesion) → pattern may be a sign of a disease, size in cm, location and distribution on body (generalized or localized?), any exudate → note color and odor Palpate lesions → roll a nodule between the thumb and index finger to assess depth Gently scrape scale to see if it comes off → note the nature of the base and note if it bleeds Note skin temp Note if lesions blanch with pressure or stretch Use magnifier and light for closer inspection Use Wood's light to detect fluorescing lesions → with the room darkened, shine the Wood's light on the area Lesions that appear with blue-green fluorescent indicates fungal infection

Vascular Lesions

Petechiae Purpura Ecchymosis Angioma

Plaques

Plaques coalesce to form surface elevation wider than 1 cm. A plateau like, disk-shape lesion ex. psoriasis, lichen planus

Normal nail findings

Smooth, pink, 160 degrees

Pressure Ulcers

Stage I - non-blanchable erythema - intact skin is red but unbroken. localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure. dark skin appears darker but does not blanch. may have changes in sensation, temperature, or firmness Stage II - partial-thickness skin loss - loss of epidermis and exposed dermis. superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed. no visible fat or deeper tissue Stage III - full-thickness skin loss - PI extends into subcutaneous tissue and resembles a crater. see subcutaneous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon Stage IV - full-thickness skin/tissue loss - PI involves all skin layers and extends into supporting tissue. exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue), rolled edges, and tunneling

Cyanosis

This is a bluish mottled color from decreased perfusion. The tissues have high levels of deoxygenated blood. Cyanosis indicates hypoxemia and occurs with shock, cardiac arrest, heart failure, chronic bronchitis, and congenital heart disease.

Interview Contract Terms

Time and place of interview and physical exam Intro of and explanation of HCP's role Purpose of interview how long it will take Expectation of participation for each person Presence of others (family, etc) (ask if it is okay to do the interview and ask questions around other members) Confidentiality and to what extent it may be limited Any costs that the patients must pay (usually nurses do not discuss cost, it is not part of our care)

Xerosis

Usually refers to rough, dry skin but it just means dry in general

Chicken pox

Vesicle

Keloid

a benign excess of scar tissue beyond sites of original injury: surgery, acne, ear piercing, tattoos, infections, burns. Looks smooth, rubbery, shiny and "clawlike"; feels smooth and firm. found in ear lobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma. Most common ages are 10-30 years; higher incidence in blacks, hispanics and asians

Angioma

a fiery red, star-shaped making with a solid circular center. Capillary radiations extend from the central arterial body. develops on face, neck or chest.

Dementia

a gradual, progressive process, causing decreased cognitive function even though the person is fully conscious and awake

Ecchymosis (bruise)

a purplish patch resulting from extravasation of blood into the skin, >3mm in diameter

Ethnicity

a social group that may possess shared traits, such as a common geographic origin, migratory status, religion, language, values, traditions or symbols, and food preferences

Chronic pain

a. Diagnoses when the pain continues for 6 months or longer b. Can be divided into malignant (cancer-related) and nonmalignant c. Chronic pain does not stop when the injury heals and originates from abnormal processing of pain fibers from peripheral or central sites.

Somatic pain

a. Originates form musculoskeletal tissues or the body surface b. Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone c. Pain may be the result from pressure, trauma, or ischemia d. Deep somatic pain is often described as aching or throbbing

Visceral pain

a. Originates from the larger internal organs (stomach, intestine, gallbladder, pancreas) b. Often is described as dull, deep, squeezing, or cramping c. Pain can stem from direct injury to the organ or stretching of the organ from tumor, ischemia, distention, or severe contraction d. Pain impulse is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system

Neuropathic pain

a. Pain that does not adhere to the typical and predictable phases in nociceptive pain b. Is pain due to a lesion or disease in the somatosensory nervous system c. This type of pain is the most difficult to assess and treat. d. Pain is often perceived long after the site of injury heals, and it evolves into a chronic condition

Acute pain

a. Short term and self-limiting pain which often follows a predictable trajectory and dissipates after an injury heals b. Acute pain warns the individual of actual or threatened tissue damage c. Ex. Surgery, trauma, kidney stones

Pain rating scale

a. numeric rating scales - asks the patient to choose a number that rates the level of pain for each painful site, with 0 being no pain and 10 indicating the worse pain ever experienced b. verbal descriptor scale - uses words to describe the patient's feelings and the meaning of the pain for the person c. visual analogue scale - lets the patient make a make along a 10-cm horizontal line from "no pain" to "worst pain imaginable"

AADL (advanced activities of daily living)

activities that an older adult performs as a member of a family, society, and community, including occupational and recreation activities.

Scar

after a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent ex. healed area of surgery or injury, acne

Delirium

an acute confusional change of loss of consciousness and perceptual disturbance; may accompany acute illnesses such as pneumonia, alcohol/drug intoxication, and is usually resolved when the underlying cause is treated

Religion

an organized system of beliefs concerning the cause, nature, and purpose of the universe. It is a shared experience of spirituality or the values, beliefs, and practices into which people either are born or that they may adopt to meet their personal spiritual needs through communal actions. Ex. religions affiliation; attendance and participation in a religious institution, prayer or meditation; and religious practices.

Polycyclic

annular lesions grow together ex. psoriasis

Palpation

applies your sense of touch to assess the following factors: texture, temperature, moisture, organ location and size, and any swelling, vibration or pulsation, rigidity or spasticity, repetition, presence of lumps or masses, and presence of tenderness or pain. i. Fingertips - best for fine tactile discrimination, such as skin texture, swelling, pulsation, and determining presence of lumps. ii. A grasping action of the fingers and thumb - to detect the position, shape, and consistency of an organ or mass iii. The dorsa (backs) of hands and fingers - best for determining temperature because the skin is thinner than on the palms iv. Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand - best for vibration

Third-level priority

are important to patient's health but can be attended to after more urgent health problems are addressed such as lack of knowledge, mobility problems, and family coping. These problems may require a collaborative effort between the patient and health care professional.

Nonmalignant pain

arthritis, low back pain etc

ADL (activities of daily living)

bathing, dressing, toileting, eating, walking

Annular or circular

begins in center and spreads to periphery ex. ringworm

Depression

being sad, gloomy, dejected' symptoms may occur with rainy weather, after a holiday, or with an illness. If the situation is temporary, symptoms fade quickly.

Malignant pain

cancer related

Tinea pedis

chronic fungal infection of the foot

Scale

compact, desiccated flakes of skin, dry, or greasy, silvery or white, from shedding of dead excess keratin cells ex. after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, micalike), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin

Inspection

concentrated watching, close, careful scrutiny, first of the individual as a whole and then of each body system. i. Begins the moment you first meet the person and develop a "general survey".

Purpura

confluent and extensive patch of petechiae and ecchymoses; >3mm, flat, red to purple, macular hemorrhage. seen in generalized disorders such as thrombocytopenia and scurvy also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis

Perception

conscious awareness of painful sensation

Respectful care

considers the values, preferences, and expressed needs of patients

Turgor

decreased skin elasticity as a result from dehydration

Ulcer

deeper depression extending into the dermis, irregular shape; may bleed; leaves scars when healed. Stasis ulcer, pressure injury, chancre

Acute symptoms

develop suddenly and are typically more responsive to treatment

Senile purpura

discoloration due to increasing capillary fragility

Discrete

distinct, individualized lesions that remain separated ex. acne

Vesicle

elevated, circumscribed lesion filled with fluid, less than 1 cm - (as the result of varicella)

Wheal

elevated, irregular shaped area of cutaneous edema (urticaria)

First-level priority

emergent, life threatening, and immediate such as establishing an airway, supporting breathing, and circulation.

Cysts

encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin ex. Sebaceous cyst, wen

you watch your hands every

every time you go into a patients room, when your hands are soiled, whenever you take off gloves, very often

Zosteriform

extremely painful and highly contagious ex. shingles-dermatomes

Stage IV Pressure Ulcer

full-thickness skin/tissue loss - PI involves all skin layers and extends into supporting tissue. exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue), rolled edges, and tunneling

IADL (instrumental activities of daily living)

functional abilities which are necessary for independent community living such as shopping, meal prep, housekeeping, laundry, managing finances, taking medications, and using transportation.

Candidiasis

fungal infection found on the skin, mucous membranes, and vagina

Effective care

has positive outcomes and satisfaction for patients

Intermittent duration pain

if the pain is not there all the time but if they do a particular movement of a limb etc. pain occurs

Confidentiality

keeping information between you and your patient

Bullas

larger than 1 cm diameter; usually single chambered (uniocular); superficial in epidermis; thin-walled and ruptures easily ex: friction blister, pemphigus, burns, contact dermatitis

Long duration pain

lasts for a longer time, lingering

Four basic concepts of culture

learned, shared, adapted, dynamic

Confluent

lesions that run together ex. hives

Fissure

linear crack with abrupt edges; extends into dermis; dry or moist ex. cheilosis --at the corners of the mouth caused by excess moisture; athletes foot

Auscultation

listening to sounds produced by the body such as the heart and blood vessels and the lungs and abdomen.

Freckles

macule

Patches

macules that are longer than 1 cm ex: mongolian spot, vitiligo, cafe au lait spot, chloasma, measles rash

Short duration pain

mains that that pain does not last very long

Types of chronic pain

malignant nonmalignant

Burning, stabbing, aching is what type of pain?

neuropathic pain

Xanthoma

nodule

Stage I Pressure Ulcers

non-blanchable erythema - intact skin is red but unbroken. localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure. dark skin appears darker but does not blanch. may have changes in sensation, temperature, or firmness

Linear

one straight lesions ex. scratching

Modulation

pain message is inhibited

Pigmented nevi (moles)

papule

Papules

papules - something you can feel (i.e.) solid, elevated, circumscribed, less than 1cm diameter) caused by superficial thiening in epidermis. ex. elevated nevus (moles), lichen planus, molluscum, wart (verruca)

Stage II Pressure Ulcers

partial-thickness skin loss - loss of epidermis and exposed dermis. superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed. no visible fat or deeper tissue

Lichenification

prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)

PQRST

provocative/palliative - what makes your pain better or worse, what seems to trigger it, what were you doing when it happened quality - what does your pain feel like region/radiation - where is your pain, does it radiate, does it move around severity - how severe is the pain on a scale of 0-10 timing - when did your pain start, how often does it occur

how do you find erythema

redness of the skin

Target

resembles the iris of an eye, concentric rings of color in the lesions ex. erythema multiform-lymes disease

where to check for jaundice

scleral icterus or conjunctiva

Erosion

scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis

Excoriation

self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching ex. insect bites, scabies, dermatitis, varicella

Macules

solely a color change, flat and circumscribed, of less than 1 cm. ex: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever

Nodules

solid, elevated, hard or soft, larger than 1 cm. May extend deeper into the dermis than papule ex. xanthoma, firoma, intradermal nevi

Wheals

superficial, raised, transient, and erythematous; slightly irregular shape from edema ex: mosquito bite, allergic reaction, dermographism

Chronic symptoms

symptoms that develop gradually and persist for a long time with poor prognosis

Percussion

tapping of the persons skin with short, sharp strokes to asses underlying structures. The strokes yield an audible vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.

Transmission

the pain impulse moves from the level of the spinal cord to the brain

Atrophic scar

the resulting skin level is depressed with loss of tissue; a thinning of the epidermis Ex. striae

Crust

thickened, dried-out exudate left when vesicles/pustules burst or dry up ex. impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion

Second-level priority

those requiring your prompt intervention to forestall further deterioration such as mental status changes, acute pain, infection risk, abnormal laboratory values, risk of safety or security, and elimination problems.

Petechiae

tiny punctate hemorrhages, 1 - 3mm round and discreet; dark red, purple, or brown in color. caused by bleeding from superficial capillaries; will not blanch. I. may indicated abnormal clotting factors

Pustules

turbid fluid (pus) in the cavity. circumscribed and elevated ex. Impetigo, acne

Gyrate

twisted, coiled, spiral, snakelike lesions ex. scabies

Diaphragm

used to hear lung, bowel, and heart sounds. Higher pitched noises

Bulla

vesicle greater than 1 cm in diameter (blister)

Objective data

what is observed by you when inspecting, percussing, palpating, and auscultating a patient

Subjective data

whatever the patient tells you

Mosquito bite

wheal

Urticaria

wheals coalesce to form extensive reaction, intensely pruritic

Spirituality

• A broader term focused on a connection to something larger than oneself and a belief in transcendence.

Focused or Problem-Centered Database

• A limited or short-term problem • Collects a "mini" database which is smaller in scope and more targeted than the complete database. • Concerns mainly one problem, cue complex, or body system. • Is used in all settings - hospital, primary care, or long term • Ex. In an outpatient clinic, a person presents with a rash. The history follows the direction of this presenting concern such as whether the rash had an acute or chronic onset; was associated with a fever, new food, pet, or medicine; and was localized or generalized. Physical examination must include a clear description of the rash.

General survey

• A study of the whole person, covering the general health state and any obvious physical characteristics. Gives an overall impression of the person.

Open-ended question

• Asks for narrative information, is unbiased which leaves the person free to answer in any way they please. • This type of question encourages the person to respond in paragraphs and give a spontaneous account in any order chosen. Allows the person to express themselves fully.

Close-ended (direct) question

• Asks for specific information which elicits a one or two word answer such as "yes" or "no", or a forced choice.

Cultural Assessment

• Assessing a patient's culture to ensure that serious errors do not occur due to a lack of cultural competence. o If you fail to ask about traditional, herbal, or folk remedies, you may unknowingly give or prescribe a medication that has a significant interaction. Ex. Ginseng raises the serum digoxin level and can lead to adverse, even fatal, consequences.

Emergency Database

• Urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures. • Diagnosis must be swift and sure • Ex. A person is brought into the ED with suspected substance overdose. The first history questions are "what did you take?" "how much did you take?" and "when?". Patient is questioned while her airway, breathing, circulation, LOC and disability are being assessed. If patient is unresponsive, health care providers may need to rely on friends and family.

Follow Up Database

• Used in all settings to follow up both short-term and chronic health problems • Ex. A patient with heart failure may follow up with his/her primary care practitioner at regular intervals to reevaluate medications, identify changes in symptoms, and discuss coping strategies.