Exam 1 / Week 4 General Survey & Skin Assessment Flashcards
What is a “general survey statement”?
The general survey is a written summary of the impressions of the client’s overall health. The nurse gathers this information from the first encounter with the client and continues to make observations throughout the assessment process.
What information should you include in a general survey statement?
The nurse will assess 5 major topics: 1. physical appearance 2. body structure 3. mobility 4. behavior, and 5. vital signs. (PA BS M B VS = pancakes and buttery syrup make breakfast very satisfactory)
List the components of the physical appearance portion of the general survey statement.
■ Age ■ Gender and race ■ Level of consciousness ■ Color of skin ■ Facial features ■ Signs of distress (pallor, labored breathing, guarding, anxiety) ■ Signs of possible physical abuse or neglect ■ Signs of substance abuse
List the components of the body structure portion of the general survey statement.
■ Body build, stature, height, and weight
■ Nutritional status
■ Symmetry of body parts
■ Posture and usual position
■ Gross abnormalities (skin lesions, amputations)
List the components of the mobility portion of the general survey statement.
■ Gait
■ Range of motion
■ Motor activity
List the components of the behavior portion of the general survey statement.
■ Facial expression and mannerisms
■ Mood and affect
■ Speech
■ Dress, hygiene, grooming, and odors (body and breath)
List the components of the vital signs portion of the general survey statement.
■ Temperature
■ Pulse
■ Respiration
■ Blood pressure
Here is a sample of a general survey statement»_space;>
Client – 16-year-old male, alert and oriented x 3. No distress noted. Personal hygiene and grooming slightly unkempt but appropriate for age. Weight appropriate for height, good posture, and steady gait. Full range of motion. Does not maintain good eye contact. Volunteers no information but answers questions appropriately when asked. No gross abnormalities noted.
When conducting the Review of Systems part of the Health History, what questions you might ask concerning the integumentary and peripheral vascular systems?
A. Have you noticed any changes in your skin color? If so, is the change widespread or just in one area?
B. Do you have a rash? Where? Does it itch? How long have you had it? What have you used to treat the rash?
C. Is your skin excessively dry or oily? Does this change with the seasons? Do you use anything to treat it?
D. Have you developed any new moles or lesions? Have any of the moles or lesions changed in any way (color, borders, size)?
E. How often are you out in the sun? Do you use sunscreen or wear protective clothing and a hat?
F. Do you have any swelling? If in your legs, is it in both legs? Does the swelling cause pain? What do you do to relieve the swelling? Does it occur at any particular time of day?
INSPECTION & PALPATION: How should you assess hair?
- Uniformity: Assess hair for uniformity. Note hair distribution patterns. Expect symmetric hair loss, as with male pattern baldness. (Alopecia can result from endocrine/nutrition issues.)
- Color: Hair color may vary due to dyes or from age.
- Cleanliness: Make note of any odors. Note any infestations of the hair.
- Texture: Expect smooth and coarse or fine hair.
INSPECTION & PALPATION: How should you assess the nails?
- Uniformity: Assess nails for uniformity. Note the curvature of the nail plate in relationship to the tissue just before the cuticle. Expect angles less than 160°. (Clubbing is an unexpected curvature of the nail with an angle great than 160°. This can result from chronic low SaO2, like with emphysema and bronchitis.)
- Color: Expect pink, symmetric nail beds. Capillary refill assesses circulation to the periphery (expect brisk return within 2 seconds.)
- Cleanliness: Make note of any odors.
- Texture: Expect firm nails.
INSPECTION & PALPATION: How should you assess the skin?
- Uniformity: Asses for uniformity.
- Color: Typically, skin color varies from ivory to ruddy to deep brown. Expect skin color of the extremities to be symmetric and similar to that of the rest of the body. Color changes are more difficult to notice in dark-skinned pt.s.
- Cleanliness: Make note of cleanliness, any odors, any infestations.
- Texture: Expect smooth, soft, even skin. Thicker skin of the palms and soles of the feet is an expected finding. Assess skin turgor. Moisture in the axillae is an expected finding, otherwise the skin should be dry.
- Temperature: Palpate the temperature of the skin with the dorsal part of the hand; check for symmetry, and expect warmth. Changes reflect circulation impairment or environmental temperature. Slightly cooler temperatures of the hands or feet are acceptable.
INSPECTION & PALPATION: Describe common color changes and their corresponding indications.
- PALLOR: loss of color in face, conjunctivae, nail beds, palms indicates anemia or lack of blood flow.
- CYANOSIS: bluish color in nail beds, lips, mouth, skin indicates hypoxia or impaired venous return.
- JAUNDICE: yellow to orange color in skin, sclera, mucous membranes indicates liver dysfunction, red blood-cell destruction.
- ERYTHEMA: redness in face, area of trauma, pressure sore areas indicate inflammation, localized vasodilation.
- BROWN: pigmentation can change with venous insufficiency.
- TRANSLUCENT: shiny skin without hair on the toes/feet indicates arterial insufficiency.
INSPECTION & PALPATION: How do you assess skin turgor?
Assess turgor by lifting and releasing a fold of skin on the forearm or sternum to verify that it returns quickly into place. Tanting is a delay in the skin returning to its usual place. Poor turgor indicates dehydration or aging and increases the risk for skin breakdown.
INSPECTION & PALPATION: List the three basic steps required to assess the peripheral arteries.
- Palpate the peripheral pulses for strength (amplitude is graded 0, 1+, 2+, 3+, 4+) and quality (symmetric in quality & quantity from the R to the L side of the body)
- With the exception of the carotid arteries, palpate pulse sites bilaterally to make comparisons.
- Inspect peripheral veins for varicosities, redness, and swelling.
INSPECTION & PALPATION: What is edema?
Edema is fluid in the tissues causing swollen, tight, and shiny skin surfaces, most often from direct trauma or impaired venous return. Assess the swelling for discoloration, location, and tenderness. In the extremities, measure the circumference of the swollen body area and compare both sides.
INSPECTION & PALPATION: How do you grade edema?
Evaluate pitting by compressing the skin for at least 5 seconds over a bony prominence and then assess. The depth of the pitting reflects the degree of edema.
1+ = 2mm, trace degree & rapid response
2+ = 4mm, mild degree & 10-15 second response
3+ = 6mm, moderate degree & 1-2 minute response
4+ = 8mm, severe degree & 2-5 minute response
INSPECTION & PALPATION: List aspects of lesions used to describe their quality.
Ask about size, color, shape, consistency, elevation, location, distribution, configuration, tenderness, fluid, and drainage. Measure height, width, and depth.
INSPECTION & PALPATION: List the primary lesions.
- Wheal (no size specified)
- Vesicle (smaller than 0.5 cm)
- Macule (smaller than 1 cm)
- Papule (smaller than 1 cm)
- Pustule (smaller than 1 cm)
- Bulla (larger than 0.5 to 1 cm)
- Nodule (1 to 2 cm)
- Patch (larger than 1 cm)
- Plaque (larger than 1 cm)
- Tumor (typically larger than 2 cm)
(Won’t Vultures Mainly Peck Piles of Bones Not Pink, Plump Tissues? because they get the leftovers or something? ew IDK??)
INSPECTION & PALPATION: List the secondary lesions.
- Erosion
- Ulcer
- Scale
- Crust
- Scar
- Keloid
- Fissure
(Every United States Citizen Should Know Ford. Mnemonics are hard)
