Weeks 3 & 4: Physical Exam, Vitals, Pain, Skin/hair/nails, violence Flashcards
what is the typical order of physical assessment (except if doing abdominal)
inspect (always first!)
palpation
percussion
auscultation
Indirect percussion technique is used to determine
what is happening in the underlying structures – evaluated by auscultating the sounds.
where do you expect to hear “resonant” sound
normal lung tissue (clear and hollow sound)
hyperresonant
in an abnormal adult lung (but a NORMAL child’s lung)
tympany
air-filled viscus (stomach, intestine)
dull
dense organ (liver, spleen)
flat
large muscles (thigh), bone, tumor
when does the general survey begin
with the first moment of encounter!
Hyper pituitary dwarfism
lack of growth hormones-disproportionate body parts
Gigantism
excessive growth hormones in body
Cushing’s disease
excess of cortisol
addison’s disease
too little cortisol
Marfan syndrome
genetic disorder affects body’s connective tissue
Syndactyly
the condition of having some or all of the fingers or toes wholly or partly united, either naturally (as in web-footed animals) or as a malformation
normal temperature ranges
“NORMAL”
oral temp is 35.8C-37.3 C (96.4F-99.1F)
Rectal temp is 0.5C (1.0F) HIGHER
Axillary temp is 0.5C (1.0F) LOWER
pulse
normal pulse of adult is 60-100 bpm (never use thumb!)
vital signs
pulse/HR BP O2 sat RR temp
korotkoff sounds
we listen for these when taking blood pressure. 5 sounds (1st sounds we hear is the systolic. Last sound is diastolic)
OXYGEN SATURATION
should be >90%. BUT, if pt is diagnosed with COPD, we do NOT want their O2 to be >90%. So, if they are at 87% we do NOT give them O2.
what pain scale do we use with demented PTs
PAINAD
Neonate responses to pain
global, evidenced by increased heart rate, hypertension, pallor, sweating, and decreased oxygenation saturation.
What intervention is most important to prevent nosocomial infections?
hand hygiene!
The patient is complaining of abdominal pain. What technique is used to form an overall impression
light palpation
Tympany is a percussion sound commonly located in the
abdomen
Percussion sounds are hyperresonant (diseased lungs), resonant (normal lungs), tympanic (abdomen), dull (over organs), and flat (over bone).
Which organs or body areas does the nurse auscultate as part of the admitting assessment
Heart, lungs, and abdomen
the diaphragm of the stethescope is used for ____ sounds
high frequency sounds (e.g. bowel sounds)
the bell of the stethescope is used for _____ sounds
low-frequency sounds (carotid arteries, bruit)
When assessing the child, the nurse makes the following adaptation to the usual techniques:
A pediatric stethoscope is used for better contact
The general survey includes
overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.
The nurse assesses the pulse for
rate, rhythm, amplitude, and elasticity
What are the four characteristics of respirations?
Rate, rhythm, depth, and quality
Oral temperature measurement is contraindicated in which patients
In PTs who have altered mental status, those who are mouth breathers, those who have had recent oral intake or who have recently smoked, and those who have recently undergone oral surgery.
what is an auscultatory gap
the period of no Korotkoff sounds during auscultation of a BP. It is caused by stiffening of the arterioles and is COMMON in the elderly and in those with chronic disease.
When performing indirect percussion, the examiner
strikes the stationary finger at the distal interphalangeal joint
A common error in BP measurement includes:
waiting less than 30 seconds before repeating the reading on the same arm
pruritis
itching
moles
nevi
striae
stretchmarks
seborrheic keratoses
extremely common in older adults!
Dark brown pigmented lesions are waxy-appearing areas seen on the trunk of the body.
actinic keratosis
aka solar keratoses (scaly, crusty growths/lesions caused by damage from the sun’s UV rays
jaundice
increased serum billirubin, carotenemia, uremia
darker people can be seen on hands and soles and feet
cherry angiomas
small (1-5mm) and increase with age
normal
typically on trunk or back
monitor to prevent changes
erythema
hyperemia (excess of blood in vessels), polycythemia, carbon monoxide poisoning, venous stasis (blood pooling
cyanosis
central (very serious), peripheral
heart not pumping blood or oxygen not getting to where it is needed
Pallor
anemia, shock, arterial insufficiency
albinism, vitiligo
Plaque
Primary skin lesion
Papules that are LARGER than 1.0 cm. Elevated, firm and rough, flat top (eczema)
lpsoriasis
Nodule
Primary skin lesion
Solid, elevated, hard or soft, larger than 1 cm.extends deeper into dermis than papule. e.g intradermal nevi
Bulla
Primary skin lesion
vesicle greater than 1cm, thin-walled, ruptures easily (blister, impetigo)
cyst
Primary skin lesion
Elevated, circumscribed, encapsulated lesion, in dermis, or subcutaneous, filled with liquid (sebaceous cyst, cystic acne)
vesicles
Elevated cavity containing free fluid up to 1 cm. - BLISTER. Clear serum flows if ruptured. e.g. herpes simplex, herpes zoster contact dermatitis
wheal
Primary skin lesion
Raised, erythematous, irregular shape e.g. mosquito bite, allergic reaction
fissure
Secondary Skin Lesions
Linear Crack or break from the epidermis to the dermis (Athlete’s foot, crack on mouth corners)
scale
Scale Secondary Skin Lesions
compact, desiccated flakes of skin, dry or greasy, silvery or white, from sheddingo f dead excess keratin cells; ex - scarlet fever or drug reactions (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin
crust
Secondary Skin Lesions
-thickened, dried out exudate left when vesicles/pustules burst or dry up; color can be red-brown, honey or yellow, depending on fluid’s ingredients (blood, serum, pus); ex - impetigo (dry, honey colored), weeping exzematous dermatitis, scab after abrasion)
Pustule
Primary skin lesion
elevated, superficial lesion, filled with purulent fluid (impetigo, acne, herpes simplex)
erosion
Secondary Skin Lesions
- scooped out but shallow depression; superficial; epidermis lost; moist but not bleeding; heals w/o scar because erosions does not extend into dermis (varicella, candidiasis, herpes simplex)
ulcer
Secondary Skin Lesions
deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals; ex - stasis ulcer, pressure sore, chancre
excoriation
Secondary Skin Lesions
self-inflicted abrasion; superficial; sometimes crusted; scatches from intense itching; ex: insect bites, scabies, dermatitis, varicella
scar
Secondary Skin Lesions
after skin lesion is repaired, normal tissue is lost and replaced w/ connective tissue (collage); this is permanent fibrotic change; ex-healed area after surgery (healed wound or surgical incision)
skin assessment in older adult
decreased sebaceous and sweat gland-dry skin
loss of elasticity, collagen and mass
subcutaneous fat migrates to abdomen
skin may be cooler with edema
gray and thinning hair
nails become thicker, brittle, hard and yellowish
Self exam of skin should include
ABCDE
look for: asymmetry border irregularity color variation diameter>6mm elevation or enlargement
vitiligo
white patches on skin. Caused by loss of pigment in skin d/t destruction of pigment-forming cell (melanocytes)
what is the skin like in a PT with hyperthyroidism
smooth, soft, velvety
what is the skin like in a PT with hypothyroidism
rough, dry, flaky
what is extremely thin and shiny skin indicative of?
arterial insufficiency
scleroderma
a chronic hardening and contraction of the skin and connective tissue, either locally or throughout the body
Assessment of lesions includes:
1. Color 2. Elevation 3. Pattern or shape 4. Size (use cm ruler) 5. Location and distribution 6. Exudate (discharge)
annular
ring shaped
confluent
flowing together or merging
discrete
lesions that are separate and discrete (e.g. molluscum)
gyrate
lesions that are coiled or twisted
grouped
lesions that appear in clusters (e.g. purpural lesion)
linear
lesions that appear as a line (scratches)
target
lesions with concentric circles of color (e.g. erythema multiforme)
zosteriform
(herpes or cold sores) arranged in a linear manner along a nerve route
polycyclic
lesions that are circular but united (e.g. psoriasis)
macule
have same characteristics as patches but are LESS than 1 cm. Flat and circumscribed e.g. freckles, petechiae, measles, scarlet fever
papule
something you can FEEL, solid, elevated, LESS than 1 cm diameter)
caused by thickening of the epidermis.
e.g. wart, elevated mole
patch
non palpable! Macules that are larger than 1 cm. e.g. cafe au lait spot, measles, rash
tumor
Larger than a few centimeters in diameter, firm or soft, deeper into dermis.
utricaria
hives
excoriation
self-inflicted abrasion; superficial; sometimes crusted; scatches from intense itching; ex: insect bites, scabies, dermatitis, varicella
atrophic scar
resulting skin level is depressed with loss of tissue; thinning of epidermis; ex – striae (stretch marks)
lichenification
secondary skin lesion
(secondary to eczema or pruritus) – exaggerated skin lines. prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)
keloid
hypertrophic scar; resulting skin level is elevated by excess scar tissue which is invasive beyond site of original injury
secondary skin lesion
- debris on skin surface: crust; scale
- break in continuity of surface
venous ulcers
happen due to venous insufficiency. Due to improper venous function, usually happen in the legs
hirsutism
excessive hair
melism
sharply demarcated blotchy, brown maculesusually in a symmetricdistribution over the cheeks and forehead and sometimes on the upper lip and neck.It is most often seen in women during pregnancy (melasma gravidarum or “mask of pregnancy”
linea nigra
black verticle line on stomach during pregnancy
varicella (chicken pox) is characterized by
single to multiple erythematous vesicles anywhere on the body. As the disease progresses, the vesicles progress into shallow ulcers covered with scabs.
measles is characterized by
a rash of macules and papules
satelitte lesions are
Single lesions in close proximity to a larger lesion
when taking the health Hx, the PT complains of pruritus. WHat is a common cause of this symptom?
allergic response
what term refers to a linear skin lesion that runs along a nerve route?
zosteriform
a scooped out, shallow depression in the skin (loss of part of the epidermis) is called
erosion
the nurse is assessing for clubbing of the fingernails and would expect to find:
an angle of the nail base of 180 degrees or greater with a nail base that feels spongy
how does the nurse recognize jaundice in a dark-skinned pt?
inspect the palms and soles for yellowish-green color
