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When assessing the present health status of a patient, symptoms of allergies, difficulty breathing and orthopnea could indicate respiratory disorders. The patient should be asked about?
The use of inhalers or oxygen at home
Assessing a patients smoking history is an important aspect of the respiratory assessment. The information should be recorded as?
The number of pack years the individual has smoked, even if he or she has already quit.
There are multiple environmental factors that can affect breathing. These include?
Air pollution, allergens in the home, and any air filtering systems in the home, hobbies and exposure to secondhand smoke.
During the part of the interview process that focuses on the respiratory system, the nurse should ask questions about the patients?
Home environment, occupational environment, and any travel that may have affected the function of the lungs
A cough may be associated with respiratory condition or caused by other problems. The patient should be asked to describe?
the cough, any sputum that is produced, and other symptoms, and what measures are used to treat he cough.
Causes of shortness of breath in a patient should be clarified. Dyspnea can be indicative of?
Respiratory or cardiac conditions. The patient should be asked to describe what makes the difficult breathing better or worse.
Common infectious respiratory conditions that may be encountered are?
acute bronchitis, pneumonia, tuberculosis, and pleural effusion.
chronic conditions include asthma, emphysema, and chronic bronchitis
Pneumonothorax and hemothorax are most often related to a?
traumatic incident. These conditions can also be associated with surgical procedures.
Inspection-Inspect for general appearance, posture, and breathing effort
Normal-
Abnormal-
Normal- The general appearance and posture should be relaxed. Breathing should be effortless, quiet, and rate is age appropriate
Abnormal- Indications or respiratory distress include an appearance of apprehension with restlessness, nasal flaring, retractions, and tripod positioning.
Observe respiration for rate, breathing pattern, and chest expansion.
Normal-
Abnormal-
Normal- Adult passive breathing is 12-20 BPM known as eupnea. The pattern should be smooth with an even respiratory depth. Symmetric rise and expansion should occur.
Abnormal-Bradypnea, tachypnea, hyperventilation, kussmaul respirations, Biot’s and cheyne-strokes patterns.
Inspect patients nails, skin, and lips for color.
Normal-
Abnormal-
Normal- Nail beds should be pink with an angle of 160 degrees at the nail bed. Skin tones vary among individuals thereby noting the general color of the client and observing if it is consistent with skin and lip color. Note presence of pallor or cyanosis
Abnormal-Cyanosis may be noted in a client with shortness of breath or dyspnea. Long term lung disease can cause spooning of the nail base greater than 180 degrees.
Inspect posterior thorax for shape, symmetry, and muscle development.
Normal-
Abnormal-
Normal- The ribs should slope down at about 45 degrees relative to the spine. The thorax should be symmetric. The spinous processes should appear in a straight line. The scapulae should be bilaterally symmetric. Muscle development should be equal.
Abnormal- Asymmetry or unequal muscle development is abnormal. Skeletal deformities such as scoliosis or kyphosis may limit the expansion of the chest. Patients with COPD may have a barrel-shaped chest.
Bronchovesicular breath sounds are?
moderate in pitch, medium in intensity, auscultated over the 1st and 2nd ICS at the sternal border and the inspiratory and expiratory duration should be equal
Vesicular breath sounds are?
Low in pitch, soft in intensity, auscultated over the inspiratory phase duration is greater that the expiratory phase duration.
Bronchial breath sounds are?
are high in pitch, loud in intensity, auscultated over the trachea, and the duration of the inspiratory phase is less than the duration of the expiratory phase.
Adventitious breath sounds are?
if heard, have patient cough, and then repeat the auscultation to note whether the adventitious sounds changed or disappeared
Fine crackles
Fine, high-pitched crackling and popping noises heard during the end of inspiration; not cleared by cough
Clinical examples- may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases.
Medium crackls
Medium pitched, moist sound heard about halfway through inspiration; not cleared by cough.
clinical examples- may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases but condition is worse than those with fine crackles.
Coarse crackles
Low pitched, bubbling, or gurgling sounds that start early in inspiration and extend into the first part of expiration.
clinical examples- may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases. condition is worse in terminally ill patients with diminished gag-reflex; also heard in pulmonary edema and pulmonary fibrosis.
Wheeze
High-pitched, musical sound similar to a squeak; heard more commonly during expiration but may also be heard during inspiration, occurs in small airways
clinical example- heard in narrowed airway diseases such as asthma.
Rhonchi
Low-pitched, coarse, loud, low snoring or moaning tone; actually sounds like snoring; heard primarily during expiration but may also be heard during inspiration; coughing may clear
clinical example- heard is disorders causing obstruction of the trachea or bronchus such as chronic bronchitis
Pleural friction rub
superficial, low pitched, coarse rubbing or grating sound; sounds like two surfaces rubbing together, heard throughout inspiration and expiration; loudest over the lower anterolateral surface; not cleared by cough
clinical example- heard in individuals with pleurisy (inflammation of the pleural surfaces)
Inspect the anterior thorax for shape, symmetry, muscle development, and costal angel. The costal angel should be? The anteroposterior diameter is about?
The costal angel should be <90 degrees
the anteroposterior diameter is about 1/2 the lateral diameter or about a 1:2 ratio of AP to lateral diameter.
Older Adult: Assessing the respiratory status of an older adult follows the same procedures as for an adult, although structural and functional differences may be noted
posterior thoracic stooping or bending or kyphosis may alter the thorax wall configuration and make thoracic expansion more difficult
When conducting a comprehensive assessment, the patient should be asked about the presence of disease affecting mobility. This includes?
Osteoporosis, arthritis, fractures, and a history of accidents or trauma.
The point where two or more bones come together
Joints
Ligaments-
Tendons-
Ligaments are flexable connective tissues that adhere bones to bones.
Tendons are nonelastic cords that are located at the end of muscles and attach muscles to bones
Common problems associated with bones are?
fractures and osteoporosis. Conditions associated with the joints are rheumatoid arthritis, osteoarthritis, burtitis, and gout.
Conditions related to the spine are?
herniated nucleus pulposus and scoliosis.
Problems linked with ligament or muscle conditions are known as?
carpal tunnel syndrom
Observe patient standing and straight from front, back, and sides.
Normal
Abnormal
Normal- the body should be symmetric. The spine should be straight with expected curvatures-cervical is concave; thoracic is convex; and lumbar is concave
Abnormal- Kyphosis, scoliosis,and lordosis
Inspect muscles for size and symmetry.
Normal-
Abnormal-
Normal- Muscle size should appear relatively symmetric
Abnormal- Atrophy of muscle mass bilaterally may indicate lack of nerve stimulation such as spinal cord injury. Fasciculations (muscle twitching) may be caused by adverse effects of drugs. Fasciculations are localized whereas spasms are more generalized.
Palpate bones for tenderness; joints for tenderness, heat, and edema; and muscles for tenderness, heat edema, and tone.
Normal
Abnormal
Normal- Bones should be non-tender on palpation. No tenderness or edema should be detected on palpation of joints or muscles. The joints and muscles should be the same temperature as the surrounding tissue. Muscles should feel firm, not hard or soft.
Abnormal- Tenderness, heat, or edema over bones, joints or muscles may indicate tumor, inflammation, or trauma. Muscle atrophy may be evident by decrease in muscle tone.
Assess range of motion for major joints and adjacent muscles, for tenderness on movement, joint stability, and deformity. (know which types of movements are associated with each type of joint, refer to table 14-1)
Normal-
Abnormal-
Normal- There should be full range of motion actively and passively with joint stability but without tenderness, heat, edema, crepitus, deformity, or contracture.
Abnormal- Crepitus which occurs after injury; limited range of motion; increased range of motion; joint instability or deformity may indicate a number of disorders including muscle weakness, fracture, inflammation, strained ligaments, or meniscus tear.
Observe gait for conformity, symmetry, and rhythm
Normal-
Abnormal-
Normal- Expected findings are cnformity (ability to follow gait sequencing of both stance and swing); regular smooth rhythm; symmetry in length of leg swing; smooth swaying; and smooth, symmetric arm swing.
Abnormal- An unstable or exaggerated gait, limp, irregular stride length, arm swing that is unrelated to gait, or any other inability to maintain straight posture or asymmetry of body parts requires further assessment.
Head and Neck INSPECT PALPATE OBSERVE PALPATE OBSERVE TEST
INSPECT musculature of the face and neck for symmetry.
PALPATE each temporomandibular for movement, sounds, and tenderness.
OBSERVE jaw for range of motion.
PALPATE the neck for pain.
OBSERVE the neck for range of motion.
TEST neck muscles for strength.
Objective: Identify findings from a musculoskeletal system assessment that would require further evaluation.
- Rheumatoid arthritis flares
* Gout
Tissue integrity refers to the?
intactness and function of the skin, hair, and nails. To maintain tissue integrity, the body needs adequate nutrition and oxygenation to carry nutrients to the tissue.
There are three main components of the skin.
- The epidermis is the outermost layer and provides no blood supply.
- The dermis is a layer which is highly vascular and regulates body temperature. It also contains sensory nerve fibers, which provide reactions to touch, pain, and temperature.
- The hypodermis is a subcutaneous layer composed of fat. Fatty cells help with heat regulation and provide protection against injury.
The most common reported skin condition is?
Pruritus (Itching).
Other common findings associated with the skin are rashes, pain, discomfort, lesions, wounds, and changes in skin color or texture.
Skin conditions common in infants and children are related to?
Diaper rashes and allergies
The most common concern in the adolescent is?
Acne
Significant changes occur in older adults with regard to?
Skin and hair
Common skin conditions that may be encountered are
corns, dermatitis, and psoriasis
Skin lesions caused by viral infections are?
warts, herpes simplex, herpes varicella (chickenpox) and herpes zoster (shingles)
Lesions of a fungal nature are ?
tinea infections and candidiasis
Bacterial infections can cause skin conditions such as?
as cellulitis, impetigo, folliculitis, and abscesses.
The most common neoplastic skin conditions are?
basal cell carcinoma, squamous cell carcinoma, melanoma, and Kaposi sarcoma.
Inspect the skin for general color and uniformity of color.
Normal
Abnormal
Normal: The skin color should be consistent over the body surface, with the exception of vascular areas such as the cheeks, upper chest, and genitalia, which may appear pink or have a reddish-purple tone. The normal range of skin color varies from whitish pink, to olive tones, to deep brown. Sun-exposed areas may show evidence of slightly darker pigmentation.
Abnormal: Abnormal skin color may be evidence of local or systemic disease. Common abnormal findings of particular importance include cyanosis, pallor, and jaundice.
Hypopigmentation
, also known as albinism (a complete absence of pigmentation; pale white skin tone is noted over the entire body surface).
Hyperpigmentation
(increased melanin deposition) may be an indication of an endocrine disorder (e.g., Addison’s disease) or liver disease.
Clinical sign: Cyanosis
light skin
dark skin
Light skin: Grayish-blue tone, especially in nail beds, earlobes, lips, mucous membranes, palms, and soles of feet
Dark skin: Ashen-gray color most easily seen in the conjunctiva of the eye, oral mucous membranes, and nail beds
Clinical sign: Ecchymosis (bruise)
Light skin
Dark skin
Light skin: Dark red, purple, yellow, or green color, depending on age of bruise
Dark skin: Deeper bluish or black tone; difficult to see unless it occurs in an area of light pigmentation
Clinical sign: Erythema
Light skin
Dark skin
Light skin: Reddish tone with evidence of increased skin temperature secondary to inflammation
Dark skin: Deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation
Clinical sign: Jaundice
Light skin
Dark skin
Light skin: Yellowish color of skin, sclera of eyes, fingernails, palms of hands, and oral mucosa
Dark skin:Yellowish-green color most obviously seen in sclera of eye (do not confuse with yellow eye pigmentation, which may be evident in dark-skinned patients), palms of hands, and soles of feet
Clinical sign: Pallor
Light skin
Dark skin
Light skin: Pale skin color that may appear white
Dark skin: Skin tone appears lighter than normal; light-skinned African Americans may have yellowish-brown skin; dark-skinned African Americans may appear ashen; specifically evident is a loss of the underlying healthy red tones of the skin
Clinical sign: Petechiae
Light skin
Dark skin
Light skin:Lesions appear as small, reddish-purple pinpoints
Dark skin:Difficult to see; may be evident in the buccal mucosa of the mouth or sclera of the eye
Clinical sign: Rash
Light skin
Dark skin
Light skin: May be visualized and felt with light palpation
Dark skin: Not easily visualized but may be felt with light palpation
Clinical sign: Scar
Light skin
Dark skin
Light skin: Narrow scar line
Dark skin:Frequently has keloid development, resulting in a thickened, raised scar
Keloid can be a result of?
Result of multiple piercings
• Pigmented nevi (moles): Moles are considered an expected finding; most adults have between 10 and 40 moles scattered over the body. They are most commonly located above the waist on sun-exposed body surfaces (chest, back, arms, legs, and face). They tend to be?
uniformly tan to dark brown, are typically less than 5 mm in size, and may be raised or flat. The expected shape of a mole is round or oval with a clearly defined border.
Freckles:
Freckles are small, flat, hyperpigmented macules that may appear anywhere on the body, particularly on sun-exposed areas of the skin. The most common locations are on the face, arms, and back.
Patch:
A patch is an area of darker skin pigmentation that is usually brown or tan and typically is present at birth (birthmarks). Some of these patches fade, but many do not change over time.
Striae:
Striae are silver or pink “stretch marks” secondary to weight gain or pregnancy.
Melanoma: The nurse should be familiar with abnormal characteristics of pigmented moles that might point to melanoma. Moles located below the waist or on the scalp or breast are?
Rarely “normal” moles
Vitiligo is an?
acquired condition associated with the development of unpigmented patch or patches; it is more common in dark-skinned races and thought to be an autoimmune disorder.
Localized areas of hyperpigmentation may be associated with?
endocrine disorders (pituitary, adrenal) and autoimmune disorders (systemic lupus erythematosus).
Skin Lesion: Macule
Examples
- Macule: flat, circumscribed < 1 cm in diameter.
- Examples: Freckles, flat nevi (moles), petechiae, measles, scarlet fever.
Skin Lesion: Papule
Examples
- Papule: elevated, firm, circumscribed area < 1 cm in diameter.
- Examples: Warts, elevated moles skin tags, cherry angiomas.
Skin Lesions: Patch
Examples
- Patch: flat, nonpalpable, irregularly shaped macule > 1 cm.
- Examples: Vitiligo, port wine stains, Mongolian spots, and Café-au-lait spots.
Skin Lesions: Plaque
Examples
- Plaque: elevated, firm, rough lesions with flat top > 1 cm.
- Examples: Psoriasis, seborrheic and actinic keratosis, eczema
Skin Lesions: Wheal
Examples
- Wheal: elevated, irregular shaped area of the cutaneous edema that is solid and varies in diameter.
- Examples: Insect bites, urticarial, allergic reactions.
Skin Lesions: Nodule
Examples
- Nodule: elevated firm, circumscribed lesions deeper into the dermis. 1-2 cm in diameter
- Examples: Dermatofibroma erythema nodusm, lipomas, hemangiomas.
Skin Lesions: Tumor
Examples
- Tumor: elevated and solid lesions that may or may not be clear in the demarcation. They are deeper into the dermis and > 2 cm in diameter
- Examples: Neoplasms, lipomas, hemangiomas
Skin Lesions: Vesicles
Examples
- Vesicles: elevated circumscribed, superficial, serous filled fluid lesions < 1 cm in diameter.
- Examples: Varicella, herpes zoster, impetigo, acute eczema
Skin Lesions: Bulla
Examples
- Bulla: vesicles > 1 cm.
- Examples: Blisters, pemphigus vulgaris, lupus erythematosus, impetigo, and drug reactions.
Skin Lesions: Pustule
Examples
- Pustule: elevated superficial lesions purulent fluid filled.
- Examples: Impetigo, acne, folliculitis, herpes simplex.
Skin Lesions: Cyst
Examples
- Cyst: elevated, circumscribed, filled with liquid or semisolid material.
- Examples: Sebaceous cyst, cystic acne
Secondary Skin Lesions: Scale
Examples
- Scale: heaped up keratinized cells, flaky skin, irregular thick or thin, dry or oily.
- Examples: Flaking of skin with seborrheic dermatitis following scarlet fever, dry skin, eczema, xerosi
Secondary Skin Lesions: Lichenification
Examples
-Lichenification: rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation.
Examples: Chronic dermatitis, psoriasis.
Secondary Skin Lesions: Keloid
Examples
- Keloid: irregular shaped, elevated progressively enlarging scar. Grows beyond the boundaries of the wound.
- Examples: Keloid formation following surgery.
Secondary Skin Lesions: Scar
Examples
- Scar: thin to thick fibrous tissue that replaces normal skin following injury or laceration.
- Examples: Healing wound or surgical incision.
Secondary Skin Lesions: Excoriation
Examples
- Excoriation: loss of epidermis linear hollowed out crusted area.
- Examples: Abrasion or scratch, scabies
Secondary Skin Lesions: Fissure
Examples
- Fissure: linear crack or break from the epidermis to the dermis. May be moist or dry
- Examples: Athlete’s foot, cracks at the corner of the mouth, chapped hands, eczema.
Secondary Skin Lesions: Crust
Examples
- Crust: dried drainage or blood, slightly elevated, variable sizes and colors.
- Examples: Scab on abrasion, eczema
Secondary Skin Lesions: Erosion
Examples
- Erosion: loss of part of the epidermis, depressed moist, and glistening, following rupture of the vesicle or bulla.
- Examples: Varicella, variola after rupture, candidiasis, herpes simplex.
Secondary Skin Lesions: Ulcer
Examples
- Ulcer: loss of epidermis and dermis, concave, and varies in size.
- Examples: Pressure ulcers, stasis ulcers, syphilis chancres
Secondary Skin Lesions: Atrophy
Examples
- Atrophy: thinning of the skin surface, loss of skin markings. Skin appears translucent and paperlike
- Examples: Aged skin, striae, discoid lupus erythematosus.
Vascular Lesions: Tangiectasia
Tangiectasia: fine, irregular red line caused by permanent dilation of a group of superficial blood vessels.
Vascular lesions: Cherry Angiomas
Cherry angiomas: small, slightly raised, bright red area that typically appears on the face, neck, and trunk of the body. These increase in size and number with advanced age.
A callus is an?
Area of excessive thickening skin that is an expected variation associated with friction or pressure over a particular surface area. A callus is commonly found on the hands or feet.
Abnormal skin findings:
Texture: Excessive dryness, flaking, cracking, or scaling of the skin may occur secondary to environmental conditions or may be signs of?
systemic disease or nutritional deficiency. Look for areas of maceration, discoloration, or rashes under skinfolds.
Abnormal finding for skin temperature
Cool Skin: Generalized cool or cold skin is an abnormal finding and may be associated with shock or hypothermia. Localization of cold skin, particularly in the extremities, may be an indication of?
cool or cold skin is an abnormal finding and may be associated with shock or hypothermia. Localization of cold skin, particularly in the extremities, may be an indication of poor peripheral perfusion. Hot Skin: Generalized hot skin is a reflection of hyperthermia. This may be associated with a fever, increased metabolic rate (e.g., hyperthyroidism), or exercise. Localized areas of skin that are hot may reflect an inflammation, infection, traumatic injury, or thermal injury such as sunburn.
Abnormal skin: Moisture: (excessive sweating) is an abnormal finding in the absence of strenuous activity. This may be a result of?
hyperthermia, extreme anxiety, pain, or shock. Excessively moist skin may often be seen with metabolic conditions such as hyperthyroidism.
Abnormal skin finding: Mobility and Turgor: Edema, excessive scarring to the skin, or some connective tissue disorders (such as scleroderma) reduce skin mobility. Poor skin turgor is noted if “tenting” is observed or the skin slowly recedes back into place. Decreased turgor may result from?
dehydration or may be a finding in an individual who has experienced significant weight loss.
Abnormal skin finding: Thickness: An increase in skin thickness is seen in patients with?
diabetes mellitus and is thought to be caused by abnormal collagen resulting from hyperglycemia. Excessively thin skin may take on a shiny or transparent appearance and is seen in hyperthyroidism, arterial insufficiency, and aging.
Abnormal hair loss on the legs may indicate?
poor peripheral perfusion
Thinning of the eyebrow is a prominent finding in?
hypothyroidism
hair growth in women with an increase of hair on the face, body, and pubic area is called?
Hirsutism
Hirsutism may be a sign of an?
underlying endocrine disorder
Dull, coarse, and brittle hair is seen with?
nutritional deficiencies, hypothyroidism, and exposure to chemicals in some hair products and bleach.
Hyperthyroidism makes the hair texture?
Fine
Alopecia (hair loss) often occurs as a manifestation of many systemic diseases, including?
autoimmune disorders, anemic conditions, and nutritional deficiencies, or treatment with radiation or antineoplastic agents.
The expected angle of the nail base is?
160 degrees
Individuals with darker-pigmented skin typically have nails that are?
Yellow or brown, and vertical banded lines may appear
Koilonychia (spoon nail) presents as?
a thin, depressed nail with the lateral edges turned upward. This is associated with anemia or may be congenital.
Leukonychia appears as?
white spots on the nail plate. This is usually caused by minor trauma or manipulation of the cuticle.
Clubbing is present when?
the angle of the nail base exceeds 180 degrees.
Clubbing is caused by?
proliferation of the connective tissue, resulting in an enlargement of the distal fingers. Clubbing is most commonly associated with chronic respiratory or cardiovascular disease.
Beau’s lines manifest as?
a groove or transverse depression running across the nail. They result from a stressor such as trauma that temporarily impairs nail formation. The groove first appears at the base of the nail by the cuticle and moves forward as the nail grows out.
Pitting of the nail is commonly associated with?
psoriasis
Thinning or brittleness of the nail may be?
secondary to poor peripheral circulation or inadequate nutrition.
Early Signs of Melanoma - To help you remember the early signs of melanoma, use the mnemonic ABCDEF (Box 9-1)
A—Asymmetry (not round or oval)
B—Border (poorly defined or irregular border)
C—Color (uneven, variegated)
D—Diameter (usually greater than 6 mm)
E—Elevation (recent change from flat to raised lesion)
F—Feeling (sensation of itching, tingling, or stinging within the lesion)
Recommendations to Reduce Risk (Primary Prevention) American Cancer Society
-Skin should be protected by sun exposure by?
- Covering with tightly woven clothing and a wide-brimmed hat.
- Applying sunscreen that has sun protection factor (SPF) of 15 or higher to exposed skin (even on cloudy or hazy days).
- Wearing sunglasses to protect the skin around the eyes.
- Seeking shade (especially at midday) whenever possible.
- Avoiding sunbathing and indoor tanning.
Screening Recommendations (Secondary Prevention) American Cancer Society
Adults should examine their skin periodically; new or unusual lesions should be evaluated promptly by a health care provider. Use the ABCDEF mnemonic for evaluating lesions.
Coining is a treatment practiced by Cambodians and Vietnamese.
The body is rubbed vigorously with a coin while exerting pressure until red marks appear over the bony prominence of the rib cage on the back and chest. Marks created by this treatment frequently have been mistaken as signs of abuse or mistreatment.
Cupping is an alternative medicine therapy for arthritis, stomach aches, bruises, and paralysis
Glass cups with negative pressure are applied to the skin; the negative pressure may be achieved by heating the air in the cups before application. As a result of the heat, the cup adheres to the skin and may leave a reddened area or mark. This is practiced by Latin American and Russian cultures.
