Notes Ch: 31 - Assessment Pt. 1 Flashcards
General-Skin-Nails
What is the purpose of the physical assessment?
S.M.I.G.E
- Support/Refute subjective data obtained in nursing hisory
- Make clinical decisions about a patient’s changing health status and management
- Identify and confirm nursing diagnosis
- Gather baseline data about patient’s health
- Evaluate the outcomes of care
What is the organization of the physical examination?
F.A.S.H.
- Follows history
- Assessment of each body system
- Systematic and organized
- Head-to-toe approach
What is a head-to-toe assessment?
A comprehensive assessment of all systems top to bottom.
What are the characteristics of a focused assessment?
- Focuses on certain system(s) in priority
- Tyically respiratory or cardiovascular
- Once stable, then proceed with comprehensive
Observing top to bottom, left to right, anterior to posterior describes what action?
Assessing for symmetry
When we perform a comprehensive assessment, we move from _____ to _____ invasive unless there is ____, which requires priority attention.
least, most, pain
You cannot _____ until you _____.
intervene, assess
Start with _____ data before going to the physical assessment.
subjective
What does HNP stand for?
History and Physical
The patient history is a _____ assessment which is comprised of what two things?
subjective
History and interview
The physical assessment provides _____ data
objective
What are the 4 techniques of physical assessment?
Briefly describe each.
- Inspection; what you see
- Palpation; what you feel with light, then deep touching
- Percussion; vibrations heard by tapping a region; indicates location size density of structures; more of an advanced MD or NP method
- Auscultation; what you hear
When using a stethoscope, listen for _____ sounds first before identifying _____ sounds or variations.
normal, abnormal
What is meant by “CC”?
Chief Complaint
What is erythema?
Superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.
What is vitiligo?
A long-term skin condition characterized by patches of the skin losing their pigment (hypopigmentation).
What types of things can be indicated by observing the color of the skin?
- Adequate blood perfusion
- Erythema
- Cyanosis
- Jaundice
How is cyanosis observed and what does it indicate?
- Blueish skin
- Observed at the mouth or mucus membranes
- Low oxygen
- Late sign of hypoxia
How is jaundice observed and what does it indicate?
- Yellowish hue in skin or sclera
- Indicates liver issues
What are some skin observations that can indicate hydration issues?
- Dryness
- Dried lips
- Sunken neck
- Turgor
What is turgor, how it is assessed, and what does inidicate?
- It is the elasticiity of the skin
- Assessed by pinching
- if the skin bounces back, decent hydration is indicated
- if the skin does not bounce back, it indicates dehydration and that fluids are needed
What are the 6 general items being observed while assessing the skin?
- Color
- Moisture
- Temperature
- Texture
- Integrity
- Turgor
What is edema?
- The medical term for swelling
When observing edema, a deeper level indicates…
fluid excess
How are the grades of edema tested?
By pressing in the effected area and assessing depth of swelling.
How are the grades of edema documented?
(give depth as well)
+1 = 2mm
+2 = 4mm
+3 = 6mm
+4 = 8mm
- *there is nothing greater than +4 on this scale,
- *+8 does not exist)
When checking for melanoma, how is “ABCDE” utilized?
- A = Asymmetry; not uniform
- B = Border; irregularity; ragged edges
- C = Color; not uniform; blue-black; white-gray; red
- D = Diameter; greater than a pencil eraser
- E = Evolving ; changing in appearance
What are some observations when assessing hair?
- Dryness
- Lice/bugs
- Thinning
- Texture
The status of hair can indicate poor ______.
nutrition
What is alopicia?
hair loss
How are the four techniques of assessment used when observing hair?
- Inspection; can see conditions
- Palpation; can feel conditions
- Percussion; N/A
- Auscultation; N/A
Nails
Oxygenation is checked at the _____.
nail bed
Nails
What is normal capillary refill time and how is it assessed?
- < than 3 seconds
- by pressing on the nail bed until white and then releasing
Nails
What is clubbing?
What are its characteristics?
What does it indicate?
- abnormal angle of the nail bed
- >180 indicates clubbing
- 160° is normal angle
- Can indicate poor circulation and heart failure
- May see in patients with COPD
a depressed, sunken neck is indicative of _____, whereas distention is indicative of ______. In either case, we will need to check _____ function.
dehydration, fluid retention, kidney
Descibe a Macule
- Flat, nonpalpable change in skin color
- smaller than 1cm
- ex. freckle
Describe a Papule
- Palpable, circumscribed, solid elevation in skin
- smaller than 1cm
- a small mole
Describe a Nodule:
- growth of abnormal tissue.
- Nodules can develop just below the skin. They can also develop in deeper skin tissues or internal organs.
- a general term to describe any lump underneath the skin that’s at least 1 centimeter in size or larger
- ex. wart
Describe a wheal
- Irregularly shaped, elevated area or superficial localized edema
- Varies in size
- Ex. hive or misquito bite
Describe a vesicle
- Raised lesion filled with serous fluid
- ex. blister
Describe Pustule
- Circumscribed elevation of skin smaller to vesicle
- filled with pus
- ex. acne, staphylococcal infection
