Exam 2 Flashcards
Why is a skin assessment important? What general information about the body as a whole is obtained through a skin assessment? Know important issues to ask when taking a history about the skin.
- You can gather clues about health problems through the skin.
- Information about body’s circulation, nutrition & signs of systemic disease.
- Past history of skin disease, change in pigmentation/color, change in mole size/shape/color/tenderness, dryness/moisture, pruritus, bruising, rash/lesion, hair loss, change in nails, etc & Rx medication
What is pallor
- Extreme or unusual paleness; skin takes color of connective tissue (collagen); common in anxiety or fear.
- Observe in mucous membranes, lips & nail beds
What is Erythema
- Intense redness from excess blood from dilated superficial capillaries
- Expected with fever, local inflammation or emotional reactions in vascular flush areas
What is cyanosis
- Bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
- Best seen in lips, nose, cheeks, ears & oral mucous membranes.
- Most conditions causing this also cause decreased oxygenation of the brain
What is jaundice
- Yellowing of skin; indicates rising amounts of bilirubin in blood.
- First noted in junction of hard & soft palates in mouth and in sclera of eye
How should we effectively assess skin temp
use backs of hand to palpate person; skin should be warm and temperature should be bilaterally equal
What is diaphoresis and what can it indicate
- profuse sweating (perspiration) - accompanies increased metabolic rate
- can indicate anxiety, pain or low BP
What is dehydration and what are some signs
- A serious reduction in the body’s water content
- dry mucous membranes, lips, decreased skin turgor
How to assess for turgor
- Infants: test mobility of skin over abdomen
- Adults: punch a large fold of skin on anterior of chest under clavicle
- Can be affected by dehydration, extreme weight loss and age
Why is an infant more susceptible to dehydration
- Higher body water content along with higher metabolic rates
- They require greater volumes of water to maintain fluid equilibrium
- Skin is thin, smooth & elastic therefor much more permeable than an adult’s
What is a papule
- small (less than 1 cm in diameter), solid, raised lesion on surface of the skin
- something you can feel
- caused by superficial thickening of dermis
ex: mole, wart
What is a nodule
- solid, round or oval elevated lesion 1 cm or more in diameter
- may extend deeper into dermis than papule
What is a tumor
- larger than a few centimeters in diameter
-firm or soft
- deeper into dermis; may be benign or malignant
What is a wheal
- superficial, raised, transient, and erythematous
- slightly irregular shape from edema
What is a pustule
raised spot on the skin containing pus
What are the abcde danger signs of lesions
- Asymmetry: not regularly round or oval
- Border Irregularity: ragged edges
- Color variation: areas of brown, tan, black, blue, red or combination
- Diameter: greater than 6 mm
- Elevation/enlargement
Describe skin developmental considerations of infant
newborns with brown/black skin have lighter skin tone than parents because of immature pigment formation; full melantonic color event in nail beds & scrotal folds
Describe skin developmental considerations of adolescence
- increased sebaceous gland activity which creates oiliness and acne
- acne lesions may appear as early as 7-8 years and peak at 14-17 in girls and 16-19 in boys.
- facial hair appears on boys first on lip, then cheeks and below lip, last on chin
- noticeable enlargement of thyroid cartilage causing deeper voice
Describe skin developmental considerations of pregnant women
- striae appear during 2nd trimester on abdomen, breasts and sometimes thighs
- vascular “spiders” are common because of increased estrogen
- thyroid gland enlarges slightly because of hyperplasia of tissue & increased vascularity
Describe skin developmental considerations of the elderly
-senile lentigines (liverspots): clusters of melanocytes appearing after extensive sun exposure on forearms & back of hand
- more prominent facial bones & orbits
- sagging facial skin as a result of decreased elasticity
- decreased subcutaneous fat & moisture in skin
What is a mongolian spot
- common variation of hyperpigmentation in newborns Black (90%), Asian (80%), American Indian (80%)
- blue/black to purple area at sacrum, buttocks and sometimes abdomen, thighs, shoulders or arms due to deep dermal melanocytes
- gradually fades in first year, frequently still lightly visible in adulthood
What is a stork bite (salmon patch)
- nevus simplex
- flat, irregularly shaped red/pink patch found on forehead, eyelid or upper lip but most commonly at back of neck
- usually fades in first year
What is a linea nigra
dark line of pigmentation from the umbilicus extending to the pubic area
What are striae
(lineae albicantes) silvery white or pink scar tissue formed by stretching of abdominal, breast and sometimes thigh skin with pregnancy (2nd trimester) or obesity
Describe the capillary refill test
- Pressure is applied to the nail bed until it turns white (called blanching) and once the tissue has blanched, pressure is removed while the patient holds their hand above their heart. Return of blood is indicated by the nail turning back to a pink color.
- healthy return is 1-2 seconds
- indicates status of peripheral circulation
Describe normal shape and contour of nails
- surface is slightly curved or flat; posterior & lateral folds are smooth and rounded
- 160 degrees
- firm to palpation
Describe clubbing
- occurs with congenital heart disease and neoplastic & pulmonary diseases which cause release of growth factors & promote vessel growth
- angle straightens out to 180 degrees, nail base feels spongy
- can reverse if primary disease is treated
What is pruritus and what can it indicate
itching; most common skin symptom.
- occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, lice etc
What is diaper rash and what can cause it
- diaper dermatitis
- red, moist maculopapular patch with poorly defined borders in diaper area extending along inguinal & gluteal folds
- infrequent diaper changes or occlusive coverings
- inflammatory diseased caused by skin irritation from ammonia, heat, moisture & occlusive diapers
What is acne
- increase in sebaceous gland activity creating increased oiliness & acne
- in milder form of open comedones (blackheads) & closed comedones (whiteheads)
Describe herpes zoster (shingles). What can it pose a risk to
- caused by varicella-zoster virus
- small grouped vesicles emerge along root of cutaneous nerve, then pustules then crust.
- accuse appearance, unilateral, doesn’t cross midline
- commonly on trunk but can be anywhere
- most common in adults 50+
- can pose risk to eye if on CN V
Describe petechiae
tiny punctate hemorrhages 1-3 mm; round & discreet; dark red, purple or brown in color.
- caused by bleeding from superficial capillaries
- may indicate abnormal clotting factors
- most diseases that cause bleeding & micro embolism formation are characterized by petechiae in mucous membranes & on skin.
- inspect in mouth, especially buccal mucosa, and conjunctivae
Describe purapura
- confluent & extensive patch of petechiae & ecchymoses; >3 mm, flat
- seen in scurvy & thrombocytopenia
- occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis
Describe hematoma
a bruise you can feel; elevates skin & seen as swelling
Describe ecchymosis
purplish patch resulting from extravasation of blood into skin, >3mm
Describe how to assess and what is the function of CN V
- trigeminal nerve
- facial sensation of pain or touch are mediated by 3 branches
- assess by gently touching 3 sections on each side of patient’s face & have them tell you when they feel it
Describe how to assess and what is the function of CN VII
- facial nerve
- forms expressions by facial muscles
- facial muscle function is bilaterally symmetric except for occasional quirk or wry expression
- assess by having patient smile, wrinkle forehead, pucker lips, show teeth & puff out cheeks; both sides of face should move the same way
Describe how to assess and what is the function of CN XI
- spinal accessory
- have patient shrug his or her shoulders and turn his or her head each way against resistance
Describe infant head growth
- Circumference grows 0.5inches/mo until 6mo, then 0.2 inches/mo until 1year
- bones of neonatal skull are separated by sutures & fontanels which allow for growth of brain during first year & gradually ossify
When does the anterior fontanel close?
between 9 months & 2 years; is also diamond shaped
When does the posterior fontanelle close?
1-2 months; is also triangular shaped
Normal findings if infant head & face
- head size should measure 32-38 cm & is 2 cm larger than chest circumference
- symmetric head contour
- skull should feel smooth & fused except for fontanels which feel firm, slightly concave & well defend against edges of cranial bones
- symmetry of wrinkling when crying or smiling
Normal finding of adult head & face
- skull should be normal and symmetric, along with facial features (eyebrows, palpebral fissures, nasolabial folds & sides of mouth)
How to palpate thyroid gland
Tilt head back to stretch skin against thyroid, inspect neck as person sips water and swallows. Thyroid tissue moves up then falls into resting position
Where is periauricular
in front of ear
Where is posterior auricular (mastoid)
superficial to the mastoid process (behind the ear)
Where is occipital
base of skull
Where is submental
midline, behind the tip of the mandible
Where is submandibular
halfway between the angle and the tip of the mandible
Where is jugulodigastric
Under angle of mandible (tonsillar)
Where is superficial cervical
overlying the sternomastoid muscle
Where is deep cervical
deep under the sternomastoid muscle
Where is posterior cervical
in the posterior triangle along the edge of the trapezius muscle
Where is superclavicular
just above and behind the clavicle, at the sternomastoid muscle
What does an enlarged lymph node mean
infection, inflammation, HIV, neoplasm
What is an acute infection
an infection characterized by symptoms that develop fairly quickly and last a relatively short time, < 14 days; nodes are bilateral, enlarged, warm tender & firm but freely movable
What is a cancerous node
rock-hard, > 3cm, unilateral, contender, matted & fixed to adjacent structures
What is the direct light reflex
constriction of the pupil when exposed to bright light
What is the indirect light reflex
(consensual light reflex) when one eye exposed to bright light, simultaneous contrition of other pupils occurs
What is the proper procedure for using the opthalmoscope
darken room to dilate pupils, select large round aperture with white light for routine examination, tell person to keep looking at mark on wall, match sides with person. begin 15 cm away from person at 15 degree lateral angle
Describe how to use the snellen eye chart
- one of several charts used in testing visual acuity; letters, numbers, or symbols are arranged on the chart in decreasing size from top to bottom
- postion person 20 ft from chart & cover one eye with opaque card.
- ask person to read smallest line of letters possible
- abnormal findings: hesitancy, squinting, leaning forward, misreading letters
Describe how to use the hand held vision screener
normally used at bedside for people older than 40, test near vision with various sizes of print, hold card in good light about 35 cm from eye, test each eye separately
Describe the corneal light reflex (Hirschberg test)
Assess the parallel alignment of the eye axes by shining a light toward the person’s eyes. Note reflection of light on corneas should be exactly the same on each eye
Describe the EOM/diagnostic positions test
leading eye through 6 cardinal positions of gaze elicits any muscle weakness during movement
What is accommodation
adaption of eye for near vision; ask person to focus on distant object, which dilates pupils, then shift gaze to near object
What are normal findings on fundoscopic examination
- internal eye exam
- optic disc will be creamy yellow-orange to pink, round or oval, distinct & sharply demarcated
- distinctness caries on cup-disc ratio; when visible. cup is a brighter yellow-white than rest of disc
What are normal findings when examining cornea and lens
No opacities (cloudiness), no abrasions, crus seniles (gray-white arc around limbus) is normal in older adults
Describe myopia
nearsightedness; lack of foresight. close objects are clearly seen but far away objects seemed blurred
Describe Ptosis
drooping of upper lid
What is aniscoria
unequal pupil size
What is diplopia
double vision; 2 images of single object
What is photophobia
inability to tolerate light
What are floaters
Particles of cellular debris that float in the vitreous fluid and cast shadows on the retina; common with myopia or after middle age
What is presbyopia
decrease in power of accommodation with aging
What is different about children’s external auditory canal and adults
Infant’s eustachian tubes are shorter, wider & more horizontal so it’s easer for pathogens to travel to inner ear
What are normal findings for otoscopic exam
- external canal should be free of redness, swelling, discharge, lesions & foreign bodies
- cerumen presence is normal
- tympanic membrane should be translucent, pearly gray, oval, slightly concave
- shorty process of malleus should be visible
What is the purpose of a eustachian tube
connects middle ear with nasopharynx & allows passage of air; normally closed but opens with swallowing or yawning; equalizes pressure to prevent membrane rupture
Which CN is responsible for hearing and equilibrium
CN VIII; acoustic/vestibulocochlear
What is the whisper test
stand 1-2 ft in front of patient, cover mouth & whisper 2 two-syllable words; test one ear at a time while other is covered
What are the signs and symptoms of Otis Media
- (middle ear in fiction) patient will feel pain, persistence of fluid in middle ear; sticky yellow discharge
- tympanic membrane will be a yellow-amber color in OM with effusion & red with acute OM
How to test CN I and what is it
Olfactory nerve. Have patient close one nostril and then sniff a smell, repeat other nostril with a different smell
Describe normal appearance and findings of inspection of nasal cavity
Inspect nasal mucosa, noting its normal red color and smooth moist surface
Observe nasal septum for deviation; deviated septum is common and is not significant unless air flow is obstructed
Inspect turbinates, the bony ridges curving down from lateral walls
Turbinates are quite vascular and tender if touched
Note any polyps, benign growths that accompany chronic allergy, and distinguish them from normal turbinates
Describe management of epistaxis
Initial management includes compression of the nostrils (application of direct pressure to the septal area) and plugging of the affected nostril with gauze or cotton that has been soaked in a topical decongestant. Direct pressure should be applied continuously for at least five minutes, and for up to 20 minutes.
How to test CN 12 and what is it
Hypoglossal nerve. cranial nerve is evaluated by asking the patient to extend the tongue and inspecting it for atrophy, fasciculations, and weakness (deviation is toward the side of a lesion)
Describe normal appearance of the mouth
Begin with anterior structures and move posteriorly
Lips - color, moisture, cracking, or lesions
Teeth and gums
Number of teeth – for adult ask if they had wisdom teeth removed? (32 - 4= 28)
Normally, gums look pink or coral with a stippled (dotted) surface
Gum margins tight and well defined
What is candidiasis and what does it look like
It is a fungus and presents as a thick looking white coat or film over the tongue
What does tonsillitis look like
White pus pockets sitting on the tonsils
Describe normal findings of the buccal mucosa
Check buccal mucosa for color, nodules, or lesions; looks pink, smooth, and moist, although patchy hyperpigmentation common in dark-skinned people – NO Cyanosis
What does normal hard palate look like
anterior
White
What does normal soft palate look like
posterior
Moist
Pink
What does normal finding of uvula look like
Midline
“Rises on phonation”
Tests one function of CN X, the vagus nerve
How to test CN IX and X (glossopharyngeal and vagus)
The gag reflex tests both the sensory and motor components of CN 9 & 10.
Describe dysphagia and what is it associated with
It is difficulty swallowing. Associated with conditions that affect the nervous system, such as a stroke, head injury, or dementia.
