Physical Assessment Chp 21 Integumentary

Question 1

Physical Assessment: Integumentary

Answer 1

Skin Characteristics:
-color
-temperature
-moisture
-texture
-turgor
As does the color, temperature, texture, and turgor of the skin offers clues to the clients health status
(Edema should also be checked)

Question 2

Observe a Lesion

Answer 2

-Any lesion, variation in pigment, or break in continuous tissue requires assessment
-Evaluate for:
>size
>shape
>pattern
>color
>distribution
>texture
>surface relationship
>exudate
>tenderness
>pain
>itching

Question 3

Lesions Considered Normal and Not Harmful

Answer 3

• Milia
• Nevi
• Skin tag
• Striae

Question 4

Skin Lesion: Milia

Answer 4

White raised areas on the nose, chin, and forehead of newborns

• resemble “whiteheads”
• due to retention of sebum in the maturing sebaceous glands
• disappear during infancy

Question 5

Skin Lesions: Nevi

Answer 5

• moles
• freckles
• birthmarks

Question 6

Skin Lesions: Skin Tags

Answer 6

tiny tags or fleshy buds of skin usually around skin creases, in middle-aged and older adults

Question 7

Skin Lesion: Striae

Answer 7

silver-to-pink “stretch marks” in pregnant women, women who have had children, and anyone who has experienced significant weight fluctuations

Question 8

Assessing the Hair

Answer 8

Use inspection and palpation to obtain data about:
-color
-texture
-distribution (ex: alopecia (hair loss))
-condition of the scalp
-clean and free of debris
-free of pediculosis (head lice)
>a client who does not properly groom her hair may need help with other self-care tasks

Question 9

Assessment of the Nails

Answer 9

Healthy Nails Beds:
-level
-firm
-similar to color of skin
-smooth and uniform in texture
>Examine both hands and feet
>Variations in color, shape or texture may indicate a health problem
-check capillary refill (indicates circulation)
-pale or cyanotic nail beds = circulatory or respiratory disorders–> result in anemia or hypoxia

Question 10

Basic Assessments: Head

Answer 10

HEENT
-Head, Eyes, Ears, Nose, Throat
Head
-size
-shape
-facial features
-symmetry
>skull should be rounded, face symmetrical
>inspect head size, unusual measure it

Question 11

Basic Assessment: Eyes

Answer 11

External eye
-sclera
-pupils
-visual acuity
-vision examination: acuity, distance, near, color, visual fields
-internal structures
>PERRLA; pupils equal, round, reactive to light and accommodation
>Pupils–> uniform in color, equal in size, round, accommodate equally (constrict + converge)

Question 12

Assessing Extra Ocular Movements

Answer 12

inspect and palpate the external eye structures, assess vision, and examine the internal eye structure

Question 13

Basic Assessments: Ears

Answer 13

Hearing + Equilibrium
-External ear: conducts sound waves to middle ear
-Middle ear: conducts sound waves to inner ear
-Inner ear: responsible for hearing + equilibrium
Test Hearing:
>Webers Test
>Rinne’s Test

Question 14

Basic Assessment: Nose

Answer 14

• Smell
• Symmetry
• Sinuses

Question 15

Basic Assessment: Mouth and Oropharynx

Answer 15

• lips
• buccal mucosa
• teeth
• gums
• tongue
• hard + soft palate

Question 16

Basic Assessment: Neck

Answer 16

• Musculature
• Trachea
• Thyroid Gland
• Cervical Lymph Nodes

Question 17

Basic Assessments: Breasts

Answer 17

• size
• shape
• nipple characteristics
• tissue
• include axillae
• mammogram- screen age 45-54 yrs
• ask about self breast exam
• only inspect (NURS 171)