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z_NUR112: MIDTERM_NOTES > Notes Ch: 31 - Assessment Pt. 1 > Flashcards

Notes Ch: 31 - Assessment Pt. 1 Flashcards

General-Skin-Nails

1
Q

What is the purpose of the physical assessment?

A

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
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2
Q

What is the organization of the physical examination?

A

F.A.S.H.

  • Follows history
  • Assessment of each body system
  • Systematic and organized
  • Head-to-toe approach
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3
Q

What is a head-to-toe assessment?

A

A comprehensive assessment of all systems top to bottom.

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4
Q

What are the characteristics of a focused assessment?

A
  • Focuses on certain system(s) in priority
  • Tyically respiratory or cardiovascular
  • Once stable, then proceed with comprehensive
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5
Q

Observing top to bottom, left to right, anterior to posterior describes what action?

A

Assessing for symmetry

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6
Q

When we perform a comprehensive assessment, we move from _____ to _____ invasive unless there is ____, which requires priority attention.

A

least, most, pain

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7
Q

You cannot _____ until you _____.

A

intervene, assess

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8
Q

Start with _____ data before going to the physical assessment.

A

subjective

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9
Q

What does HNP stand for?

A

History and Physical

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10
Q

The patient history is a _____ assessment which is comprised of what two things?

A

subjective

History and interview

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11
Q

The physical assessment provides _____ data

A

objective

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12
Q

What are the 4 techniques of physical assessment?

Briefly describe each.

A
  1. Inspection; what you see
  2. Palpation; what you feel with light, then deep touching
  3. Percussion; vibrations heard by tapping a region; indicates location size density of structures; more of an advanced MD or NP method
  4. Auscultation; what you hear
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13
Q

When using a stethoscope, listen for _____ sounds first before identifying _____ sounds or variations.

A

normal, abnormal

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14
Q

What is meant by “CC”?

A

Chief Complaint

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15
Q

What is erythema?

A

Superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.

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16
Q

What is vitiligo?

A

A long-term skin condition characterized by patches of the skin losing their pigment (hypopigmentation).

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17
Q

What types of things can be indicated by observing the color of the skin?

A
  • Adequate blood perfusion
  • Erythema
  • Cyanosis
  • Jaundice
18
Q

How is cyanosis observed and what does it indicate?

A
  • Blueish skin
  • Observed at the mouth or mucus membranes
  • Low oxygen
  • Late sign of hypoxia
19
Q

How is jaundice observed and what does it indicate?

A
  • Yellowish hue in skin or sclera
  • Indicates liver issues
20
Q

What are some skin observations that can indicate hydration issues?

A
  • Dryness
  • Dried lips
  • Sunken neck
  • Turgor
21
Q

What is turgor, how it is assessed, and what does inidicate?

A
  • 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
22
Q

What are the 6 general items being observed while assessing the skin?

A
  1. Color
  2. Moisture
  3. Temperature
  4. Texture
  5. Integrity
  6. Turgor
23
Q

What is edema?

A
  • The medical term for swelling
24
Q

When observing edema, a deeper level indicates…

A

fluid excess

25
Q

How are the grades of edema tested?

A

By pressing in the effected area and assessing depth of swelling.

26
Q

How are the grades of edema documented?

(give depth as well)

A

+1 = 2mm

+2 = 4mm

+3 = 6mm

+4 = 8mm

  • *there is nothing greater than +4 on this scale,
  • *+8 does not exist)
27
Q

When checking for melanoma, how is “ABCDE” utilized?

A
  • 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
28
Q

What are some observations when assessing hair?

A
  • Dryness
  • Lice/bugs
  • Thinning
  • Texture
29
Q

The status of hair can indicate poor ______.

A

nutrition

30
Q

What is alopicia?

A

hair loss

31
Q

How are the four techniques of assessment used when observing hair?

A
  • Inspection; can see conditions
  • Palpation; can feel conditions
  • Percussion; N/A
  • Auscultation; N/A
32
Q

Nails

Oxygenation is checked at the _____.

A

nail bed

33
Q

Nails

What is normal capillary refill time and how is it assessed?

A
  • < than 3 seconds
  • by pressing on the nail bed until white and then releasing
34
Q

Nails

What is clubbing?

What are its characteristics?

What does it indicate?

A
  • 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
35
Q

a depressed, sunken neck is indicative of _____, whereas distention is indicative of ______. In either case, we will need to check _____ function.

A

dehydration, fluid retention, kidney

36
Q

Descibe a Macule

A
  • Flat, nonpalpable change in skin color
  • smaller than 1cm
  • ex. freckle
37
Q

Describe a Papule

A
  • Palpable, circumscribed, solid elevation in skin
  • smaller than 1cm
  • a small mole
38
Q

Describe a Nodule:

A
  • 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
39
Q

Describe a wheal

A
  • Irregularly shaped, elevated area or superficial localized edema
  • Varies in size
  • Ex. hive or misquito bite
40
Q

Describe a vesicle

A
  • Raised lesion filled with serous fluid
  • ex. blister
41
Q

Describe Pustule

A
  • Circumscribed elevation of skin smaller to vesicle
  • filled with pus
  • ex. acne, staphylococcal infection

z_NUR112: MIDTERM_NOTES (14 decks)

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