1
MIDTERM WEEK 1-4
Week One: Skin, Hair, Nails, Head, Neck and Related Lymphatic
Subjective Data (always collected first)
o Info that the client experiences
Example: What they report that they ate for breakfast
o Pain
o Symptoms
o Emotional Status
o Biographical Data
Health History: info based on the client’s own perception
History of illness and injury: past and present
Family history (3 generations)
Review of Systems
Example: If you ask the pt how tall they are
Social History: alcohol, smoking, drugs, caffeine
Practices: Western Medicine, etc.
Health Patterns: exercise, diet, sleep, level of stress (what, how often, specifics)
o Note: accuracy of subjective date depends on the nurse’s ability to clarify the info
o OLDCART & ICE: used to clarify subjective data
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving Factors
Impact on ADL’s
Coping Strategies
Emotional Response
Objective Data
o What you observe by examination; measurable
o Focus on areas of interest such as chief complaint
o Done in a systematic fashion
o Examples: checking vital signs, measuring weight, auscultating the lungs
General Survey: First part of inspection; similar to head to toe assessment
o Physical Appearance
Nourishment
Color of skin (cyanotic, etc.)
Older for age
Body shape (banana, pear, hourglass, etc.)
o Mental Status
Orientation (A&Ox?)
Affect and general mood
Level of anxiety
Speech
o Mobility/Neuro
Gait (stumbling, limping, etc.)
Posture
Range of motion
o Behavior
Dress and grooming
Body odor
Facial expressions
Presence of anxiety
Eye contact
Focused Assessment
o After family history, the nurse will begin to ask more specific questions about a problem
o Enables the nurse to clarify points, collect subjective data, apply knowledge and critical thinking
, 2
Nursing Order
o Inspection
o Palpation
o Percussion
o Auscultation
o Note: order may vary depending on system
Palpation
o Light palpation: 2 fingertips in circular motion, 1cm deep
o Moderate palpation: palmer surface of fingers of the dominant hand over the structure; 2cm deep
o Deep palpation: extended fingers of the nondominant hand placed over the diners of the dominant hand; 2-4cm
Percussion
o Striking a body part to produce a measurable sound
o Used to determine the size and shape of organs
o Three types of percussion
Direct
Tapping the body with fingertips of the dominant hand
Used to assess sinuses in adults
Goal: no pain, no tenderness
Blunt
Palm of nondominant hand flat against the body surface and striking the nondominant hand with the
dominant hand
Assess pain and tenderness in gallbladder, liver, kidneys (organs=dull)
Indirect
Most commonly used; produces sound
A hammer or tapping finger used to strike an object is called a plexor
The hyperextended middle finger of the nondominant hand is placed firmly over the area being examined.
The finer is the pleximeter.
The plexor is the fingertip of the flexed middle finger of the dominant hand
Other fingers and palm raised to avoid contact with body surface
Most common percussion for abdomen
Percussion Sounds: The less dense the tissue, the louder and longer the tone
o Tympany: loud, drum-like tone, medium duration
o Resonance: loud, low pitch, hallow tone, long duration (normal lungs)
o Hyperresonance: abnormally loud, low tone, longer duration, heard when air is trapped in the lungs (emphysema, COPD)
o Dullness: high pitched, soft, short duration, heavy over solid body organs (liver)
o Flatness: high pitched, soft (muscle, bone)
Auscultation
o The skill of listening to the sound produced by the body.
o Bell low frequency (used to hear heart murmurs, bruits, thyroid glands: normal you hear nothing; hold breath, carotid arteries
=> listening for bruits or swishing sounds)
o Diaphragm high pitched sounds (bowel, lungs and heart)
o tell patient to hold breath when auscultating carotid, only do one side of the carotid arteries at a time
Vital Signs In the order in which the tests are performed
o Temperature
o Pulse (radial, BPM, if irregular check apical for 1 min)
o RR
o BP (Always last to measure)
o Pain (5th vital sign)
Korotkoff’s Sounds- (auscultate)
o Phase 1 systolic, first faint sound
o Phase 4- muffled, soft; used for a child’s diastolic
o Phase 5 diastolic, absent sound
Inspect skin perspiration is normal, cyanosis, pallor, erythema, jaundice
o Begins with a survey of the client’s appearance and a comparison of the right and left sides of the body which should be nearly
symmetrical
o Assess each body system or region for: color, size, shape, contour, symmetry, movement, drainage
o Eccrine gland: made up of water and salts
, 3
o Apocrine glands: produce a secretion made up of water, salts, fatty acids, and proteins, which is released into hair follicles.
When apocrine sweat mixes with bacteria on the skin surface, it assumes a musky odor
o B.O. at puberty
o Patchy and depigmented areas over face, neck, hands, feet = vitiligo (lighter skin tone)
Equipment used during the physical assessment
o Wood’s Lamp = fungal infection, skin assessment, sometimes used for small particles in the eyes
o Goniometer: measures the degree of joint flexion and extension
o Skinfold calipers: measures the thickness of subcutaneous tissues aka body fat
o Doppler ultrasonic stethoscope: uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope
such as fetal heart sounds and peripheral pulses (pedal pulses)
o Ophthalmoscope- used to inspect the internal structures of the eyes
o Otoscope- for the ears
Palpate skin using DORSAL hand to assess temperature down the body**
o Used to assess size, mobility, position, temperature, texture, tenderness, and vibration (fremitus)
o Temperature increased = infection, hyperthyroidism
o Begin with light palpation (finger pad, 1cm), moderate palpation (1 hand, 2cm), deep palpation (both hands, 90 degrees, 2-4cm
max),
o Temperature decreased = hypothyroidism
o Differences in temperature bilaterally = lack of circulation
o NORMAL = skin is smooth, firm, even
o SHOULD NOT report discomfort/pain
o Dry lips = dehydration
o Decreased skin turgor = dehydration
o Skin turgor below clavicle and medial wrist** (document elastic or quick rebound)
o Older patients, skin tenting
Edema decreased skin mobility caused by an accumulation of fluid in intracellular space
o +1 2 mm
o +2 4 mm
o +3 6 mm
o +4 8 mm
o Left sided heart failure → Peripheral edema with no infection
Pressure ulcers
o Stage 1 intact skin
o Stage 2 into epidermal skin layer
o Stage 3 subcutaneous tissue
o Stage 4 bone, muscle
Lesions
o When palpating lesions, use thumb and index finger
o For cancerous lesions, use ABCDE
Asymmetry
Border Irregularity
Color Variation
Diameter > 6 mm
Evolving changes
Inspection of scalp and hair
o Inspect for dandruff
o Assess texture of hair
o Assess for lesions
o Pediculosis capitis= head lice
Assessment of nails
o Assess for hygiene
o Assess for even, pink undertone
o Assess for normal shape and contour
o Assess thickness, regularity, and attachment to the nail bed
o Inspect and palpate cuticles
o NORMAL nails = well groomed, clean, convex curve, smooth, firm
o Cap refill < 3 seconds*. Check both hands
o Clubbing = hypoxia, impaired peripheral tissue perfusion. >160 degree angle (long term)
, 4
o Shamroth technique: a test to see the “diamond” when the fingernails are normal
o Spoon nails = concave, usually due to iron deficiency
o 160 degrees = normal
o Greater than 160 = Clubbing
o Less than 160 = curved nail
o Onycholysis = trauma, infection of the nails
Other
o Holistic
o Vitiligo
Papule and Plaque
● Elevated, solid palpable mass with circumscribed
border
● Papules: <0.5 cm
● Ex: moles, warts
● Plaque: > 0.5 cm
● Ex: psoriasis, actinic keratosis
Vesicle and Bulla
● Elevated, fluid filled, round or oval, palpable
● Vesicles: <0.5 cm
● Ex: herpes simplex/zoster, early*** chicken pox, small
burn blisters
● Bulla: > 0.5 cm
● Ex: contact dermatitis, friction blisters
● Early chickenpox starts on the trunk as a vesicular rash*
Macule and Patch
● Flat nonpalpable change in skin color
● Macules: < 1 cm circumscribed border
● Ex: freckles, measles
● Measles starts on the face*
● Patches: > 1 cm irregular border
● Ex: Port wine stains, Mongolian spots: gray, blue,
usually occurring in about 90% of African ancestry and
in about 80% of newborns of Asian or Native American
ancestry => dark or olive skin tones
MIDTERM WEEK 1-4
Week One: Skin, Hair, Nails, Head, Neck and Related Lymphatic
Subjective Data (always collected first)
o Info that the client experiences
Example: What they report that they ate for breakfast
o Pain
o Symptoms
o Emotional Status
o Biographical Data
Health History: info based on the client’s own perception
History of illness and injury: past and present
Family history (3 generations)
Review of Systems
Example: If you ask the pt how tall they are
Social History: alcohol, smoking, drugs, caffeine
Practices: Western Medicine, etc.
Health Patterns: exercise, diet, sleep, level of stress (what, how often, specifics)
o Note: accuracy of subjective date depends on the nurse’s ability to clarify the info
o OLDCART & ICE: used to clarify subjective data
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving Factors
Impact on ADL’s
Coping Strategies
Emotional Response
Objective Data
o What you observe by examination; measurable
o Focus on areas of interest such as chief complaint
o Done in a systematic fashion
o Examples: checking vital signs, measuring weight, auscultating the lungs
General Survey: First part of inspection; similar to head to toe assessment
o Physical Appearance
Nourishment
Color of skin (cyanotic, etc.)
Older for age
Body shape (banana, pear, hourglass, etc.)
o Mental Status
Orientation (A&Ox?)
Affect and general mood
Level of anxiety
Speech
o Mobility/Neuro
Gait (stumbling, limping, etc.)
Posture
Range of motion
o Behavior
Dress and grooming
Body odor
Facial expressions
Presence of anxiety
Eye contact
Focused Assessment
o After family history, the nurse will begin to ask more specific questions about a problem
o Enables the nurse to clarify points, collect subjective data, apply knowledge and critical thinking
, 2
Nursing Order
o Inspection
o Palpation
o Percussion
o Auscultation
o Note: order may vary depending on system
Palpation
o Light palpation: 2 fingertips in circular motion, 1cm deep
o Moderate palpation: palmer surface of fingers of the dominant hand over the structure; 2cm deep
o Deep palpation: extended fingers of the nondominant hand placed over the diners of the dominant hand; 2-4cm
Percussion
o Striking a body part to produce a measurable sound
o Used to determine the size and shape of organs
o Three types of percussion
Direct
Tapping the body with fingertips of the dominant hand
Used to assess sinuses in adults
Goal: no pain, no tenderness
Blunt
Palm of nondominant hand flat against the body surface and striking the nondominant hand with the
dominant hand
Assess pain and tenderness in gallbladder, liver, kidneys (organs=dull)
Indirect
Most commonly used; produces sound
A hammer or tapping finger used to strike an object is called a plexor
The hyperextended middle finger of the nondominant hand is placed firmly over the area being examined.
The finer is the pleximeter.
The plexor is the fingertip of the flexed middle finger of the dominant hand
Other fingers and palm raised to avoid contact with body surface
Most common percussion for abdomen
Percussion Sounds: The less dense the tissue, the louder and longer the tone
o Tympany: loud, drum-like tone, medium duration
o Resonance: loud, low pitch, hallow tone, long duration (normal lungs)
o Hyperresonance: abnormally loud, low tone, longer duration, heard when air is trapped in the lungs (emphysema, COPD)
o Dullness: high pitched, soft, short duration, heavy over solid body organs (liver)
o Flatness: high pitched, soft (muscle, bone)
Auscultation
o The skill of listening to the sound produced by the body.
o Bell low frequency (used to hear heart murmurs, bruits, thyroid glands: normal you hear nothing; hold breath, carotid arteries
=> listening for bruits or swishing sounds)
o Diaphragm high pitched sounds (bowel, lungs and heart)
o tell patient to hold breath when auscultating carotid, only do one side of the carotid arteries at a time
Vital Signs In the order in which the tests are performed
o Temperature
o Pulse (radial, BPM, if irregular check apical for 1 min)
o RR
o BP (Always last to measure)
o Pain (5th vital sign)
Korotkoff’s Sounds- (auscultate)
o Phase 1 systolic, first faint sound
o Phase 4- muffled, soft; used for a child’s diastolic
o Phase 5 diastolic, absent sound
Inspect skin perspiration is normal, cyanosis, pallor, erythema, jaundice
o Begins with a survey of the client’s appearance and a comparison of the right and left sides of the body which should be nearly
symmetrical
o Assess each body system or region for: color, size, shape, contour, symmetry, movement, drainage
o Eccrine gland: made up of water and salts
, 3
o Apocrine glands: produce a secretion made up of water, salts, fatty acids, and proteins, which is released into hair follicles.
When apocrine sweat mixes with bacteria on the skin surface, it assumes a musky odor
o B.O. at puberty
o Patchy and depigmented areas over face, neck, hands, feet = vitiligo (lighter skin tone)
Equipment used during the physical assessment
o Wood’s Lamp = fungal infection, skin assessment, sometimes used for small particles in the eyes
o Goniometer: measures the degree of joint flexion and extension
o Skinfold calipers: measures the thickness of subcutaneous tissues aka body fat
o Doppler ultrasonic stethoscope: uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope
such as fetal heart sounds and peripheral pulses (pedal pulses)
o Ophthalmoscope- used to inspect the internal structures of the eyes
o Otoscope- for the ears
Palpate skin using DORSAL hand to assess temperature down the body**
o Used to assess size, mobility, position, temperature, texture, tenderness, and vibration (fremitus)
o Temperature increased = infection, hyperthyroidism
o Begin with light palpation (finger pad, 1cm), moderate palpation (1 hand, 2cm), deep palpation (both hands, 90 degrees, 2-4cm
max),
o Temperature decreased = hypothyroidism
o Differences in temperature bilaterally = lack of circulation
o NORMAL = skin is smooth, firm, even
o SHOULD NOT report discomfort/pain
o Dry lips = dehydration
o Decreased skin turgor = dehydration
o Skin turgor below clavicle and medial wrist** (document elastic or quick rebound)
o Older patients, skin tenting
Edema decreased skin mobility caused by an accumulation of fluid in intracellular space
o +1 2 mm
o +2 4 mm
o +3 6 mm
o +4 8 mm
o Left sided heart failure → Peripheral edema with no infection
Pressure ulcers
o Stage 1 intact skin
o Stage 2 into epidermal skin layer
o Stage 3 subcutaneous tissue
o Stage 4 bone, muscle
Lesions
o When palpating lesions, use thumb and index finger
o For cancerous lesions, use ABCDE
Asymmetry
Border Irregularity
Color Variation
Diameter > 6 mm
Evolving changes
Inspection of scalp and hair
o Inspect for dandruff
o Assess texture of hair
o Assess for lesions
o Pediculosis capitis= head lice
Assessment of nails
o Assess for hygiene
o Assess for even, pink undertone
o Assess for normal shape and contour
o Assess thickness, regularity, and attachment to the nail bed
o Inspect and palpate cuticles
o NORMAL nails = well groomed, clean, convex curve, smooth, firm
o Cap refill < 3 seconds*. Check both hands
o Clubbing = hypoxia, impaired peripheral tissue perfusion. >160 degree angle (long term)
, 4
o Shamroth technique: a test to see the “diamond” when the fingernails are normal
o Spoon nails = concave, usually due to iron deficiency
o 160 degrees = normal
o Greater than 160 = Clubbing
o Less than 160 = curved nail
o Onycholysis = trauma, infection of the nails
Other
o Holistic
o Vitiligo
Papule and Plaque
● Elevated, solid palpable mass with circumscribed
border
● Papules: <0.5 cm
● Ex: moles, warts
● Plaque: > 0.5 cm
● Ex: psoriasis, actinic keratosis
Vesicle and Bulla
● Elevated, fluid filled, round or oval, palpable
● Vesicles: <0.5 cm
● Ex: herpes simplex/zoster, early*** chicken pox, small
burn blisters
● Bulla: > 0.5 cm
● Ex: contact dermatitis, friction blisters
● Early chickenpox starts on the trunk as a vesicular rash*
Macule and Patch
● Flat nonpalpable change in skin color
● Macules: < 1 cm circumscribed border
● Ex: freckles, measles
● Measles starts on the face*
● Patches: > 1 cm irregular border
● Ex: Port wine stains, Mongolian spots: gray, blue,
usually occurring in about 90% of African ancestry and
in about 80% of newborns of Asian or Native American
ancestry => dark or olive skin tones
