Ch. 8,9,12,13- Assessment Techniques, General Surgery, Nutrition Assessment, Skin, Hair, and Nails Flashcards
In most cases perform assessment techniques in what order?
- Inspection
- Palpation
- Percussion
- Auscultation
What are you assessing when using palpation?
- texture/temp/moisture (use back of hands)
- swelling
- pulsations
- organ location/size
- muscle rigidity/spasticity
- crepitus (“rice Krispy sensation”)
- lumps/masses
- tenderness/pain
What is percussion?
Tapping person’s skin with short, sharp strokes to assess underlying structures
Percussion has what uses?
- Mapping location and size of organs
- Signaling density or a structure by a characteristic note
When using percussion, a structure with more air produces what sounds?
louder, deeper compared with denser structures
When using percussion only what should be touching the patient s skin?
distal joint and tip of middle finger
Explain the quality and location of a resonant percussion note?
amp: medium/loud
pitch: low
quality: clear/ hollow
duration: moderate
sample location: over normal lung tissue
Explain the quality and location of a tympany percussion note?
amp: loud
pitch: high
quality: musical and drum like
duration: sustained longest
sample location: over air-filled viscous (ex: stomach, intestines)
Explain the quality and location of a dull percussion note?
amp: soft
pitch: high
quality: muffled thud
duration: short
sample location: relatively dense organ as liver or spleen
The diaphragm of a stethoscope is what?
Flat edge, for high-pitched sounds
The bell of a stethoscope is what?
Deep, hollow, cuplike, for low pitched sounds
The general survey is a study of the whole person which includes what?
-Overall immediate impression of a person
including physical appearance, body structure, mobility, behavior
What objective data do we include when assessing a persons physical appearance?
- Age
- LOC/orientation
- Skin color
- Facial features
- Overall appearance
What objective data do we include when assessing a persons body structure?
- Stature
- Nutrition
- Symmetry
- Posture
- Position
- Physical deformities
What objective data do we include when assessing a persons mobility?
- Gait
- Extremity movement
- ROM
What objective data do we include when assessing a persons behavior?
- Facial expression
- Mood and affect
- Speech
- Dress
- Personal hygeine
What things should be done when obtaining weights?
- Aim for same time of day
- trend weights/ observe changes
- outpatient= remove shoes and heavy outer clothing
What things should be done when obtaining heights?
- use wall-mounted/pole on scale devices
- pt. shoed be shoeless, standing straight, looking straight ahead
What is BMI?
-Practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition
The aging adult typically has what physical appearances?
- sharper body contour
- more angular facial features
- subcutaneous fat lost from face and periphery
The aging adult typically has what posture characteristics?
forward flexion occurs by eighth or ninth decade
The aging adult typically has what type of gait?
- wider base to compensate for diminished balance
- steps may be shorter or uneven
Adult emergence of metabolic syndrome is a concern leading to what risk?
increased cardiac risk
What is sarcopenia?
age-related loss of muscle mass
What is sarcopenia obesity?
low muscle mass with excess fat
Who are at increased risk to develop undernutrition or over nutrition?
people as they age
What are major risk factors for malnutrition in older adults?
- poor physical or mental health
- social isolation
- alcoholism
- limited functional ability
- poverty
- polypharmacy
What are the purposes of nutritional assessment?
- identify individuals who are malnourished or a at risk of developing malnutrition
- provide data for designing a nutrition plan of care
- various data collection methods
What are types of nutritional objective data?
- Observation of general appearance
- Height
- Weight
- BMI
What are other areas to asses during a skin inspection?
- under large breasts
- obese abdomen
- groin
What areas should always be assessed for skin breakdown?
Pressure points and folds
What objective data is collected when assessing skin color?
- General pigmentation, freckles, moles, birthmarks
- widespread color change
What objective data is collected when assessing skin temperature?
- Use back of hands to palpate person
- skin should be warm, and temp equal bilaterally
- hands and feet may be slightly cooler in a cool environment
What objective data is collected when assessing skin moisture?
- Diaphoresis
- Dehydration
What other objective data is collected when assessing skin?
- Texture/thickness
- edema
- mobility and turgor (use fold under clavicle)
- vascularity and bruising
What are compound nevus?
macular and papular.
intradermal nevus has nevus cells in only the dermis
What is Vitiligo?
acquired condition: complete absence of melanin pigmentation in patchy areas white or light skin on the face, neck, hands, feet, and body folds around orifices
What are vascular lesions?
Vascular lesions are relatively common abnormalities of the skin and underlying tissues, more commonly known as birthmarks. There are three major categories of vascular lesions: Hemangiomas, Vascular Malformations, and Pyogenic Granulomas.
If any lesions are present, note what objective data?
- Color
- Elevation
- Pattern or shape
- Size
- Location and distribution on body
- Any exudate (drainage): note color and odor
Wat objective data should be noted when assessing nails?
- Shape and contour
- Consistency
- Color
- CRT (normal is <3 seconds)
What is clubbing?
Lost profile sign associated with chronic lung disease.
What objective data should be recorded when assessing hair?
- Color
- Texture
- Distribution
- Lesions
What hair/skin/nails changes do we see in the aging adult?
- Elasticity lost, skin folds and sags
- Sweat and sebaceous glands decrease, dry
- Senile purpura (discoloration due to increasing capillary fragility)
What is the ABCDEF skin assessment used for?
Teach skin self-examination to rule to detect suspicious lesions
What is the ABCDEF skin assessment?
- A: Assymmetry
- B: Border
- C: Color
- D: Diameter (>6mm is concerning)
- E: Elevation
- F: Ugly Duckling (does it stand out?)
