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Nursing Fundamentals > Skin, Hair, Nails and HEENT: 6 Questions > Flashcards

Skin, Hair, Nails and HEENT: 6 Questions Flashcards

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1
Q

What is the Integumentary System?

A

Skin, Hair, Nails, Scalp

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2
Q

Palpation includes ?

A

Moisture, Texture, Turgor, and Temperature

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3
Q

Inspection includes?

A

Visible Surface first
Less visible surfaces as you examine each body system

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4
Q

Cyanosis is what?

A

(Blue Lips) which means low oxygen , nail beds, palpebral conjunctiva, palms

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5
Q

Pallor is what?

A

Paleness, buccal mucosa, conjunctiva, nail beds

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6
Q

What is Vitiligo?

A

Face, Hands, arms

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7
Q

What is Jaundice?

A

Yellow -Orange, sclera, mucous membranes, skin

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8
Q

What is Erythema?

A

Red, common in areas of pressure, but can be anywhere.

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9
Q

What is Vascularity?

A

Localized reddened, pink, or pale skin.

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10
Q

What is Petechiae?

A

Nonblanching, pinpoint-size, red or purple spot

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11
Q

What is normal skin moisture?

A

Smooth and dry with moist skin folds (such in the axillae

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12
Q

What is excessive perspiration?

A

Activity, warm environment, obesity, anxiety, excitement.

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13
Q

What is excessively dry?

A

Dullness, dryness, crusting, and flaking
Common in older adults, lack of humility, sun exposure, smoking, dehydration.

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14
Q

How do you get skin temperature?

A

Palpate the skin bilaterally with the Dorso side of the hand.

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15
Q

How do you assess skin texture?

A

Lightly palpate skin by using fingertips.

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16
Q

What is skin Turgor?

A

Skin elasticiity

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17
Q

Where do you assess skin turgor?

A

Grasp a fold of skin on the back of the forearm or sternum with the fingertips
DO NOT CHECK ON THE BACK OF HANDS

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18
Q

What is good turgor ?

A

Skin immediately falls back into place

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19
Q

What is poor turgor?

A

skin stays pinched (Tenting)=Dehydration

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20
Q

How to inspect Edema ?

A

Location
Color
Shape

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21
Q

How to palpate Edema ?

A

Mobility
Consistency
Tenderness

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22
Q

What do you not forget while assessing for edema?

A

Don’t forget to assess the Backside

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23
Q

What is the Braden Scale Assessment ?

A

Helps determine a patients risk for skin breakdown

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24
Q

What is stage 1 pressure injury?

A

Localized “Red” not blanched

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25
Q

What is stage 2 pressure injury?

A

Exposed dermis, skin missing

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26
Q

What is stage 3 pressure injury?

A

Full thickness skin loss, adipose tissue

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27
Q

What is stage 4 pressure injury?

A

Skin, tissue, muscle, bone, and cartilage loss becomes exposed

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28
Q

What is a deep tissue injury?

A

Deep Maroon/Purple discoloration, Dark wound bed, blood=blister

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29
Q

What is unstageable?

A

Covered by stuff

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30
Q

What are lesions ?

A

Any unusual finding of the skin

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31
Q

What are the ABCDE of Skin Malignancies?

A

Asymmetry
Border irregularity
Color
Diameter
Evolution

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32
Q

What are Nits?

A

White, yellow, or tan “dots” eggs attached on hair shaft.

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33
Q

What is Lice?

A

White/grayish bodies

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34
Q

What are crabs?

A

Red Legs

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35
Q

How should nails be assessed?

A

Inspect and Palpate

36
Q

What degree do you assess nail beds?

A

160 degrees

37
Q

What color are nail beds dark skin patients?

A

Pink with white nail tips

38
Q

What color are nail beds for lighter skin patients?

A

Darkly pigmented, blue or reddish hue

39
Q

How should you assess the change in the nail angle?

A

Between the base and the nail is 180 degrees or more

40
Q

What is nail clubbing ?

A

Enlarged fingertips and nail flattening

41
Q

What does nail clubbing indicate ?

A

COPD

42
Q

Opaque-yellow brittle dull, or thick nails indicates ?

A

Insufficient Calcium

43
Q

Where should you look for Pallor ?

A

In the lower palpebral conjunctiva and tongue

44
Q

How do you assess the Head and Skull?

A

Inspection and Palpation

45
Q

What three things do you assess for the Head/Skull?

A

Position (head should be upright and midline to the trunk.
Size (should not appear unusually large or small)
Shape and Contour (Skull round with prominences in the frontal and occipital areas. No nodules or masses.

46
Q

How to assess for facial features?

A

Inspection

47
Q

What do you inspect the face for ?

A

Shape and Symmetry

48
Q

What are the Head, Skull, Facial Features abnormal findings?

A

Tremors, hearing loss, Acromegaly

49
Q

Are Eyes External or Internal structures?

A

External Structures

50
Q

How do assess the eyes?

A

Inspection and some palpation-clean gloves

51
Q

How many times do you blink a minute?

A

20 times per min

52
Q

How do you position the eyes?

A

Parallel….no bulging (exophthalmos), protrusion, or crossed eyes (strabismus)

53
Q

What tool do you use for eye exam?

A

Penlight

54
Q

How many directions do you gaze ?

A

6 directions

55
Q

What type of movements do your eyes do for the exam ?

A

Extra-ocular Movements

56
Q

What is Nystagmus?

A

Abnormal Gaze far left or right

57
Q

What test is for distant vision?

A

Snellen Chart

58
Q

How far do you stand from the Snellen Chart ?

A

20 feet
Read each line with each eye
Note smallest eye accurately

59
Q

What test do you for Near Vision?

A

Read aloud a handheld/printed material.

60
Q

What are the ears?

A

Auricles

61
Q

How do assess the ears ?

A

Inspection (size, shape, symmetry, landmarks, position, color, discharge)

62
Q

What are the normal ears?

A

Equal size/level, vertical, top even with outer canthus of eye, same color as face, yellow cerumen (Earwax)

63
Q

What tool do you use for Inspection of the ears?

A

Otoscope

64
Q

What do you inspect in the ears?

A

Tympanic Membrane

65
Q

What is the Rinne Test?

A

Single and Behind the ear. Mastoid Process and patients response to hear.

66
Q

What is the Weber Test?

A

Midline patients top of the forehead, can the patient hear the sound equally?

67
Q

What is the Whisper Test?

A

Random numbers/equal syllables, each ear, one at a time while patient occludes the other ear.

68
Q

How do assess the nose ?

A

Inspection and Palpation

69
Q

External Nose ?

A

Shape, size, skin color, any deformity or inflammation. Palpate ridge and soft tissue for tenderness, masses, deviations.

70
Q

Patency of Nares

A

Occlude one naris and have patient breathe with closed mouth. Repeat with other naris.

71
Q

What is Sinus tenderness?

A

Palpate with thumbs using gentle upward pressure over the frontal sinuses, under the eyebrows, and over the maxillary sinuses.

72
Q

What equipment is used for Mouth and Pharynx inspection?

A

Clean gloves, tongue depressor, gauze, penlight

73
Q

Lips Inspection

A

color, texture, hydration, contour, lesions
* View with mouth closed

74
Q

Teeth Inspection

A

symmetry of smile, color of teeth, presence of caries, tartar,
extraction sites
* Have clench teeth and smile, then open mouth

75
Q

Mucosa/Buccal Mucosa

A

color, hydration, texture, lesions
* Open mouth, retract lips away from teeth, retract cheeks with tongue depressor,
illuminate w/penlight

76
Q

Gums Inspection

A

color, edema, retraction, bleeding, lesions
* Inspect while cheeks retracted with tongue depressor

77
Q

Tongue and Floor of Mouth

A

movement, color, position,
texture, coatings, lesions
* Have stick out tongue halfway, raise tongue and move side to side, lift tongue
and place tip on palate
* Illuminate with penlight and inspect all surfaces and underside

78
Q

Hard and Soft Palates

A

Color, shape, texture, extra bony
prominences or defects
* Have tilt head backward/hold mouth open. Inspect roof of mouth.

79
Q

Pharynx

A

color and texture. edema, petechiae, lesions, exudate?
* Have tilt head back slightly and say “ah”, place tip of depressor on middle
third of tongue.

80
Q

How do you assess the neck?

A

Inspection and Palpationlocation, size, consistency, mobility, tenderness, warmth

81
Q

Neck has what?

A

Lymph Nodes

82
Q

NECK MUSCLES

A

Sternocleidomastoid and trapezius muscles
Inspect symmetry of neck muscles, range of motion, any discomfort

83
Q

TRACHEA

A

normally located midline above
suprasternal notch

84
Q

THYROID GLAND

A

fixed to trachea w/ isthmus at midline, two cone-shaped lobes at each side.

85
Q

Labs

A
  • CBC
  • Nasal swab (Covid, flu)
  • Culture
  • Throat swab (strep)
86
Q

MEDICATIONS

A

Eye drops/ointments
* Nasal spray
* Ear drops
* Oral medications
* Topical medications

Nursing Fundamentals (10 decks)

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