Skin, Hair, Nails, Head, Neck, and Eye Assessment Flashcards
made under sterile conditions
and at very low to no risk for
infection. Usually skin or vascular
incisions
Clean wounds
made under sterile conditions but involving the
respiratory, GI, genital, urinary tract without unusual contamination.
Clean-contaminated wound
exposed to content of GIT or infected fluids from GUT
Contaminated wound
exposed to contaminants or
exhibiting evidence of infection prior to surgery.
Infected wound
*No inflammation
*No break in sterile technique
*Wound primarily closed/Not drained
*Aero- digestive, genitourinary & Biliary tract not entered
*Potential infection rate
Clean Wounds
*Traumatic Wounds
*Acute inflammation present
*Major break in sterile technique
*Gross spillage/contamination from respiratory, gastrointestinal, biliary, or genitourinary tracts
*Potential infection rate 15%-20%
Contaminated wounds
*No inflammation
*Minor break in sterile technique
*Aerodigestive or genitourinary tract entered without spillage
*Potential infection rate 8%-10%
Clean-contaminated wound
*Old Traumatic wounds
*Clinical infection present
*Perforated Viscus
*40% expected infection rate
*Devitalized tissue
Class IV Wounds (dirty) or Infected Wounds
an abnormal collection
of CSF in the ventricles of the brain causing enlargement of the cranium. (separation of cranial sutures, bulging fontanels and dilated veins across the scalp)
HYDROCEPHALUS
developmental delays and congenital abnormalities are associated with maternal intake of alcohol during pregnancy. (microcepahly, flattened
check bones and upper lip, small eyes)
FETAL ALCOHOL SYNDROME (FAS)
results from either extra chromosomes 21 or translocation of chromosomes 14 or 15 with 21 or 22. (microcephaly, flattened occipital bones, slanted small eyes,
depressed nasal bridge low set ears and protruding tongue).
DOWN SYNDROME (Trisomy 21)
due to diet deficient in iodine. (puffy facial features and often a larger than normal tongue.
CONGENITAL HYPOTHYROIDISM
premature closure
and ossification of the fontanels result in cranial deformities and microcephaly.
CRANIOSYNOSTOSIS
congenital or acquired contraction of the sternocleidomastoid muscle causing the head to inclined to one side. (ROM is decreased)
TORTICOLLIS
overproduction of growth
hormones resulting to thickening of the skin, subcutaneous tissue and facial bones and coarsening of facial features
ACROMEGALY
paralysis usually unilateral of
the facial nerve (CN VII) can be transient or permanent. Common causes include trauma, compression and infection.
BELLS PALSY
excessive
production of exogenous ACTH results in a round “moon” facies, fat deposits at the nape of the neck, “buffalo hump”, and sometimes a velvety discoloration around the neck (acanthosis nigricans).
CUSHING SYNDROME
a degenerative
neurological disease which presents a masklike facial appearance, rigid muscles,
diminished reflexes and a shuffling gait.
PARKINSON DISEASE
or brain attack.
Embolism, hemorrhage, or vasospasm in the brain results in ischemia of surrounding tissue and neurological damage. Symptoms depend on the part of the brain affected
CVA/STROKE
hardening of the skin usually noted in the hands and face. Skin becomes firm and loses mobility seemingly fixed to underlying tissues
SCLERODERMA
enlarged thyroid gland
(hyper/hypothyroidism)
GOITER
severe hypothyroidism, presents periorbital swelling and edema of the face, hands, and feet.
MYXEDEMA
Assessment of Visual Acuity
● Distance Vision
● Near Vision
● Color Vision
the patient reads the letter 20 ft. away
Snellen test
(pocket screener) or ask the
patient to read newsprint
Jaeger test
Color vision (Identifying colors)
Ishihara Cards
61-92 cm (2-3 ft.) directly in front of the patient. Examiner’s eye and
patient’s eye should be on the
same level but cover the other
side w/o pressure while the
examiner present 1-4 finger
midway between 4 quadrants
Static Confrontation
examiner’s eye and patient’s
eye should be on the same level
but instruct the patient to say
“now” when the fingers 1st
come to view. Wiggle fingers
from a distal point moving them
towards the center.
Kinetic Confrontation
test for strabismus. Instruct to stare
straight ahead at the bridge
of your nose. Stand in front
of the patient and shine a
penlight at the bridge of the
pt’s. nose.
Corneal Light Reflex
(Hirschberg test)
for presence and amount of ocular deviation. The light level should be low, with no direct light sources shining in the pt’s. eyes. The extraocular muscles should have very little activity
Cover test
allows to detect muscle defects
that cause misalignment or
uncoordinated eye movements.
Cardinal fields of gaze test
inspect eyebrows,
lashes, and eyelids; note eye shape and symmetry.
▫ Lacrimal apparatus
▫ Bulbar conjunctiva
▫ Cornea and lens
Assessment of External Eyes
▫ Iris
▫ Pupil – PERRLA
Assessment of Exterior Ocular Structure
▫ Disc: cup disc, rims pink and healthy
▫ Vessels: signs of Arteriovenous (AV) nicking
▫ Macula: flat, good light reflex off the surface
▫ Periphery: lattice or tears
Assessment of Internal Ocular Structure
Nearsightedness is a vision condition in which people can see close objects clearly, but objects farther away appear blurred.
Myopia
Farsightedness is a common vision condition in which you can see distant objects clearly, but objects nearby may be blurry
Hyperopia
a common and generally treatable imperfection in the curvature of the eye that causes blurred distance and near vision.
Astigmatism
farsightedness
caused by loss of elasticity
of the lens of the eye,
occurring typically in
middle and old age.
Presbyopia
Types of Strabismus
*Esotropia
*Exotropia
*Hypotropia
*Hypertropia
Outward turning
Exotropia
Inward turning
Esotropia
Downward turning
Hypotropia
Unward turning
Hypertropia
