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NURS2240 test 1
na
39
Nursing
Undergraduate 2
01/14/2013

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Term
Chest/Lung assessment: IPPA
Definition
Inspect
Palpate
Percuss
Auscultate
Term
PQRSTU
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"
Term
Neuropathic pain: what is it, what is unique about it and at what level does it occur.
Definition
Abnormal processing of pain message
Most difficult type of pain to assess & treat
Neurochemical level
Term
Pain transmission: what is the pathway and the name of the tract
Definition
Nociceptor ---> Dorsal horn ---> crosses midline ----> Thalamus/Limbic/cortex

Anterolateral Spinothalamic Tract
Term
Visceral, Deep somatic, cutaneous, referred pain definitions
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
Term
Acute vs Persistent pain
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
Term
Pain assessment questions (for reference, probably not test material)
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?
Term
Integumentary Assessment: what is it part of, what will be incorporate it into?
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)
Term
What should be in the back of your mind when doing integument assessment?
Definition
communicable diseases, alleries
Term
Functions of the skin: Protects against? What does it regulate/synthesize? What does it sore and excrete? What does it allow?
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
Term
Skin anatomy and physiology
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
Term
Nails should be:
Definition
Smooth, thin, and flexible
Term
Good places to pick up jaundice
Definition
soles of feet or palms of hand, palate, eyes
Term
Integumentary system special considerations for aging: elasticity, sebum production, perspiration, melanin, nails
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
Term
Other factors affecting skin, hair and nail health
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
Term
Color variations in skin - pallor: possible causes, central vs peripheral
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
Term
Color variations: absence of colour: causes and names of two specific examples
Definition
Absence of Color

Congenital or acquired loss of
melanin pigment
Congenital loss typically
generalized (albinism), acquired loss typically patchy (vitiligo)
Term
Color variations in the skin - cyanosis: characteristics, cause, where most apparent
Definition
Mottled blue color in skin due to
inadequate tissue perfusion with
oxygenated blood
Most apparent in nails, lips, oral
mucosa, tongue.
Term
Color Variations: uremia and brown
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
Term
COlor variations - erythema: definition, generalized vs localized, examples of when it's normal.
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”
Term
Color Variations: Jaundice definition where most apparent first
Definition
Yellow undertone due to increased
bilirubin in blood
Generalized, most apparent in
conjunctivae & mucous
membranes first
Term
Color variations - Carotenemia description, cause, where most apparent
Definition
Yellow-orange tinge caused by
increased levels of carotene in the
blood & skin
Most apparent in face, palms of
hands, soles of feet
Term
Abnormal findings - skin, types of lesions
Definition
primary lesions
secondary lesions
vascular lesions
infections
malignant lesions
Term
Lesion configurations: annular, confluent, discrete, grouped, gyrate, target, linear, polycyclic, zosteriform
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)
Term
Primary lesions - definitions, bunch of examples
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
Term
Papule vs Plaque
Definition
circumscribed, elevated, solid lesion,
< 1 cm
Plaque: >1cm
Term
Vesicle vs Bulla
Definition
small, superficial, circumscribed skin elevation, < 0.5 cm, containing serous fluid
Bulla > 0.5 cm
Term
Pustule
Definition
small (< 1 cm), circumscribed, superficial elevation, filled with purulent material
also described as a vesicle filled with pus
Term
Secondary lesions - how formed and a bunch of examples
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
Term
Vascular lesions - how caused and a bunch of examples
Definition
result of changes in vessel integrity
Hemangioma
Port-wine stain
Spider angioma
Venous lake
Ecchymosis
Hematoma
See Jarvis text 256-257
Term
Purpuric lesions - Petechiae
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
Term
Purpuric Lesions
Definition
Purpura
Flat, red to purple
Irregularly shaped
(>3 mm)
Extensive patches
Caused by:
Bleeding disorders
thrombocytopenia
Scurvy
Capillary fragility in elderly
Term
Infections/inflammatory skin lesions
Definition
Measles (rubeola, rubella)
Varicella (chicken pox)
Tinea pedis (athlete’s foot)
Psoriasis, Eczema, Dermatitis
Herpes (simplex “cold sore”, zoster – shingles)
Impetigo
Term
Malignant lesions
Definition
basal cell carcinoma
squamous cell carcinomas
Kaposi’s sarcoma
malignant melanoma
Term
ABCDE for skin cancer
Definition
Asymmetry
Borders
Colour
Diameter (no more than 6mm)
Elevation
Term
Hair abnormalities
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
Term
Seborrhea
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
Term
Folliculitis and Furuncles
Definition
Infected hair follicle.... furuncle also called boil.
Term
Nail abnormalities: splinter hemmorhage, onycholysis, clubbing, paronychia, spoon nails
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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