NURS 1145 Final

• Cyanosis


  - blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen

  
  

  - common causes: Hypoxia, Anemia, Hypotension
• Jaundice


  - yellowish pigmentation of the skin, the conjunctival membranes over the sclera, and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood)

  
  

  - transcutaneous or blood/serum bilirubin testing
• Erythema


  - redness of skin
• Pallor


  - skin appears a pale color which can be caused by illness, emotional shock or stress, stimulant use, lack of exposure to sunlight, anemia, hypotension
• Skin Turgor


  - elasticity of skin

  
  

  - to test for dehydration

  
  

  - elderly have poor turgor so not an accurate test for dehydration in elderly

  
  

  - to test: pick up skin and slightly pinch the skin on the forearm or clavicle. Skin should easily move when lifted & should return to place immediately
• Pitting Edema Scale


  1+ A barely perceptible pit, 2mm

  2+ A deeper pit, rebounds in a few seconds, 4mm

  3+ A deep pit, rebounds in 10-20 seconds, 6mm

  4+ A deeper pit, rebounds in >30 seconds, 8mm
• Petechiae


  - caused by tiny hemorrhages w/in the dermal or submucosa due to intravascular defects and infection

  
  

  - less than 0.5cm in diameter
• Ecchymosis


  - caused by trauma to the blood vessel resulting in bleeding under the tissue

  
  

  - variable in size

  
  

  - bruising
• Hematoma


  - mass of extravasated blood confined to a space

  
  

  - caused by a break in a blood vessel
• Skin lesion ABCDE rule

  A-asymmetry

  B-border

  C-color (red,black,gray,pink)

  D-diameter

  E-elevation and enlargement

  
  

  -is it smooth? / has it changed?
• Primary Skin Lesions


  ─ Macule

  ─ Urticaria

  ─ Papule (hives)

  ─ Patch

  ─ Vesicle

  ─ Plaque

  ─ Cyst

  ─ Nodule

  ─ Bulla

  ─ Wheal

  - Plaque ─ Pustule

  ─ Tumor
• Secondary Skin Lesions


  ─ Crust

  ─ Scale

  ─ Fissure

  ─ Erosion

  ─ Ulcer

  ─ Excoriation

  ─ Scar

  ─ Atrophic scar

  ─ Lichenificat ion

  ─ Keloid
• Macule


  - flat, round area, that's a change in color of skin

  
  

  - less than 1 cm

  
  

  -ex; freckles, flat moles
• Papule


  - elevated, firm, round area

  
  

  - fluid or blood filled

  
  

  - less than 1 cm

  
  

  - wart, elevated moles, skin tags
• Reflex Scoring


  0=no response

  1+=slugglish or diminished response

  2+=active or expected response

  3+=slightly hyperactive

  4+=brisk, hyperactive w/ intermittent clonus

  5+=sustained clonus (tremors/seizure disorder)

  
  

  (2 normal / 3 may also be normal)
• Babinski Response


  - run object lightly across later side of sole of foot starting at heel and ending at the big toe

  
  

  -normal: toes curve inward & foot everts

  
  

  -abnormal: big toe dorsal flexes & other toes fan out. Normal in infants. Indicates damage to CNS.
• Kernig's Sign


  - Meningitis Test:

  
  

  - Have pt. lay supine. Lift leg at hip, bend at knee, then extend at knee.

  
  

  normal: no pain

  
  

  abnormal: pain along length of spine
• Brudzinski"s Sign


  - Meningitis Test:

  
  

  - Have pt. lay supine. Bring pt's head upwards so chin is close to chest

  
  

  normal: no pain or resistance

  
  

  abnormal: pt. flexes hip & knee in response to this & reports pain in spine
• Pustules


  - elevated, superficial lesion

  
  

  -similar to a vesicle but filed with purulent fluid

  
  

  - infection

  
  

  - ex: impetigo, acne, herpes, folliculitis
• Wheals


  - elevated irregular-shaped area of cutaneous edema; solid, transient

  
  

  - ex: insect bites, allergic reaction, lupus
• Spinal cord levels related to reflexes

  Brachioradial = C5, C6

  Biceps = C5, C6

  Triceps = C6, C7, C8

  Quad = L2, L3

  Patellar = L2, L3, L4

  Achillies = S1, S2
• Adduction


  movement of limb towards the body
• Abduction


  movement of limb away from the body
• S/S of Syphilis (3 stages)

  - Primary: single painless genital lesion 10 days to 3 months after exposure

  
  

  - Secondary: Generalized skin rash, enlarged lymph nodes, red macules on hands & feet, round and gray lesions may appear, fever may appear 2-4 weeks after appearance of lesions; may last for several years

  
  

  - Latent: Usually no clinical signs present for as long as 20 years; may continue to involve & damage neurologic & cardiac organs; dementia, confusion, paralysis may occur
• S/S of Gonorrhea


  - Men: purulent penile discharge, dysuria, frequency of urination

  
  

  - Women: Dysuria, abnormal menses, yellow or green discharge, PID, vaginal burning & itching may be severe

  
  

  - Oral sex can lead to symptoms of pharyngitis

  
  

  - gram negative
• Cranial Nerves and Functions

  1 - Olfactory (Smell)

  2 - Optic (Vision)

  3 - Oculomotor (Eyeball Movement)

  4 - Trochlear (Eyeball Movement)

  5 - Trigeminal (Chewing/Teeth Clenching)

  6 - Abducens (Eyeball Movement)

  7 - Facial (Smiling)

  8 - Acoustic (Hearing)

  9 - Glossopharyngeal (taste)

  10 - Vagus (taste)

  11 - Spinal accessory (trapezius & sternocleidomastoid)

  12 - Hypoglossal (taste/tongue movement)
• McMurray's test


  - Used to evaluate pt. for tears in the meniscus of the knee.

  
  

  - Medial Meniscus Assessment: internally rotate leg so the toes point inward. Flex the pt's knee then extend while still having the leg internally rotated.

  
  

  - Lateral Meniscus Assessment: Externally rotate leg so the toes point outward. Flex the pt's knee then extend while still having the leg externally rotated.

  
  

  - Normal: Pt should experience no pain or have no "clicking" noise present when performing the test

  
  

  - medial meniscus tear is more common than lateral
• Romberg test

  - test for balance

  
  

  - pt stands with feet together, arms rested at the side, and eyes closed

  
  

  - Normal: Slight swaying but maintained upright position and foot position

  
  

  -Abnormal: A loss of balance indicating cerebellar disorder or vestibular dysfunction
• PERRLA


  P=Pupils are

  E=Equal

  R=Round and

  R=React to

  L=Light and

  A=Accommodation
• Accommodation


  - Have pt stare at an object across the room (about 20 ft away)

  
  

  - Have pt shift their gaze to your finger which should be 6 inches from their nose

  
  

  - distance=pupils dilate

  - close=pupils constrict
• Confrontation


  - test for peripheral vision

  
  

  - Have pt close one eye & you close opposite eye. have the pt stand looking at you.

  
  

  - Move hands from 50, 60, 70 , & 90 degrees from side into line of vision

  
  

  - Have pt tell you when they first see the pen

  
  

  - Normal=pt see's object when you do
• S/S of HPV

  - most common STD

  
  

  -Pale, soft papally lesions found around the internal & external genitalia & perianal & rectal areas of body

  
  

  - Profuse watery vaginal discharge, dyspareunia (painful intercourse), intense pruritus & vulvar itching

  
  

  - Women have risk for cervical cancer

  
  

  - Men may or may not have lesions
• Symptoms of Menopause


  - Irregular periods

  - Decreased fertility

  - Vaginal dryness

  - Hot flashes

  - Sleep disturbances

  - Mood swings

  - Increased abdominal fat

  - Thinning hair

  - Loss of breast fullness
• Pupillary light reflex


  - Dim lights in room, have pt hold eye open & gaze at an object across the room

  
  

  - Approach with a penlight beam from the side & shine directly into pupil (Repeat w/ other eye)

  
  

  - Findings should be PERRLA - size=2-6mm
• Cataract


  - opacity of the crystalline lens

  
  

  - Comes from denaturation of lens protein or trauma

  
  

  - Pt reports cloudy or blurred vision

  
  

  - Cloudy lens can be observed. Red reflex is absent & light cannot penetrate the opacity.
• Muscle Strength


  - Ask pt to flex the muscle being evaluated & then resist when you apply opposing force against the muscle

  
  

  - There are 3 scales to test: Lovett scale, grading, & percent of normal

  
  

  - Muscle strength should be a 5, bilaterally symmetric, w/ full resistance to opposition. Documentation of 5/5
• Muscle strength scale


  0=no evidence of contractility

  1=evidence of slight contractility

  2=complete ROM w/ gravity eliminated

  3=complete ROM w/ gravity

  4=complete ROM against gravity w/ some resistance

  5=complete ROM against gravity w/ full resistance
• Risk factors for CVA (Cerebrovascular Accident)

  - Age

  - Gender (men have greater risk than women)

  - Family history

  - Race (African American have greater risk)

  - Previous CVA

  - smoking

  - Diabetes Mellitus

  - Atherosclerosis / obesity / high cholesterol

  - Excessive alcohol / cocaine usage
• What are you looking for when you trans-illuminate the scrotum?

  masses / testicular cancer
• S/S of testicular torsion


  - sudden & severe onset of pain & swelling of the scrotum

  
  

  - caused by twisting of the testicles & spermatic cord, cutting off blood supply (surgical emergency)

  
  

  - testicles become tender, not associated w/ trauma or physical activity