the integumentary Flashcards
• This includes the skin, hair and nails
• Methods to perform are inspection and palpation
integument
Skin Condition
• Color:
⚬ Pallor/Jaundice/Cyanosis. etc.
• Texture:
⚬ Dryness/Wrinkling/Excessive moisture
• Temperature:
⚬ Warm/Cold/Clammy
• Lesions:
⚬ Papules/Wounds etc
Increased amount of deoxygenated hemoglobin
- hear or lung disease, can be in cold environment
(can be seen at nail beds, lips, mouth & skin)
bluish (cyanosis
(associated with hypoxia) decrease in color
~ Reduced amount of oxyhemoglobin
~ Reduced visibility of oxyhemoglobin resulting from decreased blood flow
(anemia shock)
pallor (decrease color)
Increased deposit of bilirubin in tissues
- yellow-orange in color
jaundice
Increased visibility of oxyhemoglobin caused by dilation or increased blood flow
- erythema
red/ erythema
not normal skin color
• Pallor
• Cyanosis
• Jaundice
• Erythema
Eyes
• Eye brows : Normal/Absent
• Eye lashes: Infection/Stye
• Eye lids: Oedema/Lesions
• Eye balls: Sunken/Protruded
• Sclera: Jaundiced
• Pupils: Dilated/Constricted reaction to light
• Lens: Opaque/Transparent
• Eye muscles: Strabismus (Squint)
• Vision: Normal/Myopia/Hypermetropia
terminologies for eyes
❖Myopia - nearsightedness
❖Hyperopia - farsightedness
❖Presbiopia - loss of elasticity of the lens hence loss of ability to see close objects
❖Conjunctivitis - inflammation of the conjunctiva
❖Cataract- opacity of the lens
terminologies for eyes
- nearsightedness
myopia
terminologies for eyes
- farsightedness
hyperopia
terminologies for eyes
- loss of elasticity of the lens hence loss of ability to see close objects
presbiopia
terminologies for eyes
- inflammation of conjunctiva
conjunctivities
terminologies for eyes
- opacity of the lens
cataract
Extra ocular movement
• Make the patient to sit _______ away from the nurse.
• Hold a finger about ______ away from the patient.
• The client keeps the head fixed and follows the movement of the
nurse’s finger with only the eyes
- 2 feet
- 30 cm
Tuning fork test
- Weber’s Test (Lateralization of sound)
- Rinne Test (Air and Bone condunction)
Assessment of Thorax
- Normal
- Barrel chest
- Pectus Carinatum
- Pectus Excavatum
Fremitus is a faintly perceptible vibration felt through the chest wall when the client speaks (1,2,3 or 99 or blue moon etc)
Jugular Venous Pressure
Blood pressure in the jugular vein, which reflects the blood volume and pressure in the right side of the heart
Blood pressure in the jugular vein, which reflects the blood volume and pressure in the right side of the heart
Jugular Venous Pressure
● Done to assess the collateral circulation of the upper extremities.
● The client make a fist as the ulnar and radial arteries are compressed simultaneously.
Allen’s Test
● Used to assess the adequacy of the arterial supply to the leg
Buerger’s Test
● Place the patient in supine position.
● Raise both of the patient’s feet to 45 degree angle for 1-2 minutes.
● Observe the color of the limbs:
• Sit the patient up and ask them to hang their legs down over the side of the bed:
Buerger’s Test
