Neuro Checks and Integument Assessment Flashcards
1
Q
The Quick Neuro Check
A
- Level of Consciousness (LOC)
- Orientation
- Communication
- Motor response
2
Q
Neuro Check: LOC Assessment
A
- Alert; awake, responding to questions
- Lethargic; not fully alert, kind of drifting to sleep if not talking to them, might seem a bit drowsy, able to still answer questions but seem a bit fuzzy; common if coming from surgery
- Obtunded; sleeping most of the time, difficult to arouse, in speech may be one word answers or mumbling, not making a lot of sense
- Stupor; spontaneously unconscious, drifting in and out, any vocalization may be groan or mumble, rely only awake and attending to us if we give a strong stimulus (maybe a painful one). But still have appropriate responses to pain
- Coma; no response to stimulus, may still have some reflexive movement
3
Q
Neuro Check: Orientation
A
- Person, place and time
- If they’ve met you before, do they remember, do they know where they are, do they know what time it is (approximate time)
- Developmental considerations for children
4
Q
Neuro Check: Communication
A
- Gross screen; looking for if they are appropriately responding to what we’re asking them, can they carry a conversation, is it making sense, are they articulate?
5
Q
Neuro Check: Motor response
A
- Appropriately moving all their limbs, any significant restrictions in movement, consider all functional limitations
6
Q
Layers of the skin
A
- Epidermis – think but tough layer, bound tightly layer to form protective barrier, avascular (no blood vessels) but nourished by dermis underneath
- Basal Cell Layer; layer that forms new skin cells, lots of keratin present, as well as melanin
- Horny Cell Layer; most outer layer, consists of dead skin cells that are constantly being shed off and being replaced by new ones - Dermis – inner supportive layer, consists mostly of collagen (connective tissue that’s tough and stretchy), found nerves, sensory receptors, blood vessels, lymphatic vessels, hair follicles, sweat glands, oil glands originate
- Subcutaneous layer – layer of adipose tissue, stores energy and temperature control, gives us a cushion effects; looseness gives us the mobility across underneath structures.
7
Q
Epidermal appendages: Hair
A
- Threads of protein, threads of ketatin
- Arrector Pili; muscle that contracts whenever you have goose bumps, when cold, emotional states
- Vellus; very fine, faint hair that covers most of body
- Terminal; darker hair that presents during puberty
8
Q
Epidermal appendages: Sebaceous glands
A
- Sebum; lipid substances, purpose it to lubricate skin and hair and makes an emulsion that prevents water loss; found all over body except palms of hands and soles of feet
9
Q
Epidermal appendages: Sweat glands
A
- Eccrine glands – open up directly onto skin, produce sweat, through the evapouration of sweat we cool our body. Infants less than 2 months don’t have fully developed (can’t sweat to cool down)
- Apocrine glands – don’t becomes active until puberty, thinker milky secretion that open up into hair follicles. Mixes with bacteria flora to produce body odour
10
Q
Epidermal appendages: Nails
A
- Hard plates of protein (keratin)
11
Q
Functions of the skin (9)
A
- Protection – of underlying structures
- Guards the body – barrier to stop microorganisms
- Perception – touch, temperature, pressure, vibrations
- Temperature regulation – give off heat, store heat through adipose layer
- Identification – fingerprints, characteristics
- Communication – emotional states, blushing, blanching
- Wound repair – cell replacement of surface wounds on skin
- Absorption and excretion – absorb UV light to produce vitamin D, limited ability to excrete metabolic waste
- Production of vitamin D
12
Q
Infant considerations in integument assessment
A
- Lanugo; fine hair that covering infants at birth
- Vernix; white, lipid substance that covers newborn; protects skin while living in utero
- Milia; tiny white bumps usually on face or bridge of nose, from excess sebum at birth
- Eccrine glands not functional during first few months of life – can’t sweat
- Subcutaneous layer insufficient – until about 6 months; infants aren’t very good at thermoregulating
13
Q
Adolescent considerations in integument assessment
A
- Increased secretion from the apocrine glands
- Sebaceous glands become more active
- Subcutaneous fat deposits increase – especially in pelvic area in females
14
Q
Pregnant persons considerations in integument assessment
A
- Linea nigra – brownish/darker black line done midline of abdomen, response to extra hormones in body, fades after delivery
- Cholasma – hormonal changes, irregular hyperpigmented area usually on face, can fade after delivery but can persist
- Striae gravidarum – stretch marks, result of connective tissue becoming fragile from being stretched
15
Q
Older persons considerations in integument assessment
A
- Decreased elasticity, subcutaneous fat & muscle tone – drier, thinner, and more-lax (more hanging quality to it) and more wrinkles
- Sweat and sebaceous glands decrease in number and function
- Decreased melanocytes – causes greying
- Hair distribution changes – thinning, blading; can begin around mid 30s
16
Q
Subjective assessment of the integument
A
- Previous history of skin disease
- Change in pigmentation
- Change in a mole
- Excessive dryness or moisture
- Pruritus (itching)
- Excessive bruising
- Rash or lesion (PQRSTU-AAA)
- Medications
- Hair loss
- Change in nails
- Environmental or occupational hazards
- Self-care behaviours
17
Q
Inspecting the skin
A
- Colour - general pigmentation, consistency
- Temperature – backs of hands, compare bilaterally, expect skin to feel warm, equal on both sides, hands and feet may be slightly cooler
- Moisture – perspiration appears if warm or anxious, any perfuse perspiration (excessive sweating), look at mucous membranes should be smooth pink and moist
- Texture – skin smooth, form, consistent, any variation
- Thickness – normally outer epidermal is think, common to be thicker on palms, soles, callouses
- Edema – swollen, fluid accumulated in tissues, unexpected finding, may reasons (cardiac issues, respiratory issue, infection issue, etc.)
18
Q
Colours of the skin
A
- Pallor – paleness, anemic, shock
- Erythema – redness
- Cyanosis – blueness or greyness, not enough oxygen either systemically or to an area
- Jaundice – yellowing, there is an increased level of bilirubin in the body; infection, lever illness, physiological jaundice
19
Q
Edema scale
A
4 point scale
- 1+= mild pitting, slight indentation, no perceptible swelling
- 2+= moderate pitting, indentation subsides rapidly
- 3+= deep pitting, indentation remains for a short time, limb looks swollen
- 4+= very deep pitting, indentation lasts a long time, limb is very swollen
20
Q
Mobility and turgor
A
- mobility is ease at skin comes up
- turgor is ability of skin to return back to resting (turgor poor with poor hydration, tenting found in older people)
21
Q
Vascularity or bruising of skin
A
- Are they noticing prominent veins in legs, varicose veins, unexplained bruising
22
Q
Lesions on skin
A
- Colour
- Elevated or not
- Shape
- Size,
- Location,
- If it has any exudate (any kind of fluid coming out of it),
- If so; colour and odour
23
Q
Inspecting and palpating hair
A
- Colour – changes
- Texture – consistency, patches that are thin
- Distribution – generally hair all over body, places where expect hair and there is not and vice versa
- Lesions – separate hair to look in between scalp should be smooth, clean, free of lesions and free of bugs
