Week #1 Concept Review Flashcards
Techniques: Skin, Hair, and Nails
What are the four basic techniques of physical assessment?
Inspection, Percussion, Palpation, and Auscultation
What technique is used initially in any physical assessment?
Inspection technique
What is the tool used for auscultation? What are the diaphragm and the bell used for?
A stethoscope, the diaphragm is used for high-pitched sounds that includes the lungs, the bell is used for low pitched sounds like Bruits and Cardiac Murmurs
What tools are used to assess during percussion? Name two-techniques and when they are used?
The use of the middle fingertips of the dominant hand, may be direct or indirect. Indirect assesses the lung tissue. Direct assesses; nasal congestion or sinus headache.
What is blunt percussion? Provide an example?
A type of percussion using the palm of the non-dominant hand flat over the CVA (Costovertebral Angle) of body area, the tapper is the closed fist of the dominant hand.
An example would be the assessment of a kidney injury when there is a hematoma noted at the CVA.
What tools are used during palpation? Provide an example of what can be assessed?
The finger pads and/ or metacarpophalangeal joint or ulnar part of the hand. An example, tactile fremitus (ask the patient to state 99, assess placements bilaterally).
What is the best technique to assess the lymph nodes?
Gentle circular motions
What is the best technique to assess Skin Turgor?
Pinching below the clavicles & below the wrist bilaterally
What is the best assessment for jaundice in dark skinned individuals?
Inspection of the lips, oral mucosa, sclera, conjunctiva, and soles of palms/ feet.
Why wash hands before and after every physical client intervention?
To protect examiner and client against the spread of infection.
Name the three skin layers and the second layers components
The top layer is the epidermis, and the second layer is the dermis. the dermis contains nerves, blood vessels, hair follicles. The third layer is the subcutaneous layer which is followed by muscle and bones.
What is a doppler?
An instrument used to assess pulses when pulses cannot be palpated.
What is a wood lamp?
An instrument used to assess for fungal infection of the skin
What is a skinfold caliper?
An instrument used to measure thickness subcutaneous tissue.
What is a stadiometer?
An instrument used to measure height
What is a goniometer?
An instrument used to measure joint extension and flexion
Describe a stage 1 decubitus ulcer
First layer of skin intact, erythematous lesion & non-blanchable
Describe a Stage II Decubitus Ulcer
A lesion involving 2 layers of tissue, bleeding is observed with partial thickness loss
Describe a Stage III Decubitus Ulcer
Lesion involving 3 layers of tissues- epidermis, dermis, and subcutaneous tissue. Full-thickness loss, slough can be present.
Describe a Stage IV Decubitus Ulcer
A lesion involving 4 layers of tissue- epidermis, dermis, and subcutaneous tissue and muscle and bones. Full thickness loss, eschar is present or dead tissue
When a client suddenly refuses your assessment or exam, what should you do as a Nurse?
Document what was done and what was refused by the client.
How is “grading of skin edema” performed?
Press around bony prominences of the body with your third finger pads of both hands. Grade zero- no edema. 1+=2 MM, 2+= 4 MM, 3+= 6 MM, 4+= 8 MM
Where are the popliteal pulses located?
located behind the knees medially
Where is the radial pulse located?
Located laterally when hands are in supine position at the wrists in line with the thumbs.
Where are the ulnar pulses located?
Located medially when the hands are supine position at the wrist in line with the little fingers
Where are the brachial pulses located?
The brachial pulses are located at the antecubital area of the arms
Where are the femoral pulses located?
The femoral pulses are located at the inguinal areas
Describe an annular lesion
A lesion with one circle configuration (Ex. Ringworm or tinea corporis)
Describe a target lesion
A lesion with concentric circles of colors inside a lesion with a dot at the center. A.K.A. bull’s eye lesion because of the dot at the center of the lesion. (Ex. erythema)
Describe a group lesion
Lesions that appear in clusters or are together (Ex. a purpuric lesion)
Describe a confluent lesion
Lesions that run together (Ex. Urticaria)
Describe discreet lesions
Lesions that are separate (Ex. Molluscum-AKA wart)
Describe a wheel lesion
A lesion that is reddened with irregular borders caused by insect bite or hive
What is “Port Wine Stain”
A vascular lesion on the face that is flat, deep purple red and irregularly shaped and deepens when person cries or when when the person is highly emotional or exposed to high environmental temperature. Typically, does not fade.
Describe Spider Angioma
A vascular lesion, flat, bright red dot with tiny radiating blood vessels ranging from pinpoint to 2 cm
Describe venous lake
A vascular lesion on the face, neck, ears, or lips usually common in 50 year old or older, soft, compressible, slightly elevated and ranges from dark blue to purple. May be due to sun exposure.
Describe lichenification
Lesions that are rough, thickened, hardened epidermis due to constant scratching and/ or rubbing
Describe atrophy
A lesion that is translucent, dry, paper like, sometimes wrinkled due to loss of collagen and elastin
Describe a keloid
A lesion that is elevated, irregular darkened area of excess scar tissue
Describe ABCDE Criteria
Criteria used to rule out a malignant lesion.
A- Asymmetry, B- Border Irregular, C- Varied Colors, D- Diameter (more than 6 mm), and E- Evolving Change
Describe Malignant Melanoma
The most serious type of skin cancer because is spread rapidly to the lymph and blood vessels, varied colors, irregular border, and greater than 6 mm
What are the predisposition or risk factors of skin cancer?
Overexposure to the UV light and genetic predisposition
List the order of occurrence of Herpes Zoster S/S
1) Paresthesia (burning or tingling sensation)
2) Redness and swelling
3) Vesicles/ Blisters
4)Weeping Blisters/ Vesicles
5) Crusted lesions
6) Post-herpetic neuralgia (pain and burning sensation long after blisters disappear.
*Cause of Shingles or Herpes Zoster-Chickenpox Virus
What are expected findings on a client with Herpes Zoster
Painful lesion that follow along the nerve pathway
When assessing a client for physical abuse…?
The first action of the nurse is to report to the supervisor then document.
Newborn- Describe Mongolian Spots
harmless purplish-blue spots on the sacral area that are usually common in dark skinned infants. Disappears by age 3.
Newborn-what is vernix caseosa?
Harmless white cheese like mixture of sebum and epidermal cells on the skin of the newborn baby. Disappears after several bathing’s.
Newborn-What is lanugo?
Fine downy hair in a newborn prominent on the upper chest, shoulders, and back.
Newborn- What is milia?
Pimple like whiteheads on the nose or cheeks of the newborn which will disappear after 2-3 weeks
Newborn- What is vitiligo
Harmless white patchy, depigmented area over the face, neck, hands, and skinfolds of newborn baby. Does not disappear.
When an infant’s skin appears white, pale blond hair and pink iris, what condition does the baby have?
Absence of Color
What are the 2 types of hair?
Vellus hair & Terminal Hair
Describe Vellus Hair
fine, pale short hair located all over the body, except lips, nipples, palms, and soles of feet (peach fuzz)
Describe terminal Hair
Longer coarser hair located on the eyebrows. scalp, axilla, legs, and for males (face and chest)
What are the three Stages of Hair Growth Cycles?
Anagen Phase- growth phase, 2-6 Years
Catagen Phase-transitional Phase- 2 Weeks
Telogen Phase-Shedding-1-4 months
Describe alopecia areata
Sudden loss of hair in a round balding patch on the scalp, can be an autoimmune disease & aggravated by stress
How should clubbing of the nails be assessed?
Have the client bring the dorsal aspect of the corresponding fingers together to created a mirror image- normal findings- diamond shaped space between fingers with 160-degree angle of the nail beds.
What is Koilonychia
Soft nails that appear spoon shaped due to malnutrition
What is Oncholysis
A fungal nail infection, nail thicken, appears white, yellow opaque and lifts off from the nail bed
What are beau lines?
Linear depression at the base of the nail and moves distally as nail growth occurs due to trauma or illness
Describe Paronychia
Infection of skin adjacent to the nail cause by bacteria or fungi
What is a therapeutic response when a client refuses a male nurse to take care of her?
I’ll arrange for a female nurse to care for you.
What is jaundice?
Skin findings of a client with cirrhosis of the liver
What is an indication of physical abuse, and what should a nurse do?
Bruises in various stages of healing on a client is a possible indication of physical abuse. The most appropriate action of the nurse is to report the findings to the supervisor.
What is the first action of the nurse in the nursing process
Collection of data, subjective and objective. Subjective is data stated by the client. Objective is data you can see, feel, smell, and hear during your assessment.
Describe Pediculosis Capitis
White particles tightly attached to the hair shaft
What is Tinea Pedis
Athlete’s Foot
What id the sequence of the skin, hair, and nails assssments?
1) Inspection
2) Palpation
