PHYSICAL ASSESSMENT MIDTERM STUDY GUIDE Week 1 Skin, Hair, and Nails, Head, Neck, and Related Lymphatic

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PHYSICAL ASSESSMENT MIDTERM STUDY GUIDE
Week 1 Skin, Hair, and Nails, Head, Neck, and Related Lymphatic
● Subjective (subjective data always collected first)
○ Info that the client experience
○ Pain
○ Symptoms
○ Emotion
○ Health history (in the order)
○ History of illness and injury
○ Family history
○ Review of system
○ Social history
○ Patient has a new diagnose with Hepatitis C. Ask patient about history of piercing and tattoos (because
Hepatitis C is transmitted through blood).

● Objective data
○ What you observe by examining
○ Focus on areas of interest - such as chief complaint
○ ex. checking vitals

● General Survey (1st part of inspection) similar to head to toe assessment
○ Physical appearance
■ Nourishment
■ Color of skin - cyanotic etc.
■ Older for age
○ Mental status
■ Orientation (A&O x 4)
■ Affect and mood
■ Level of anxiety
■ Speech
○ Mobility
■ Gait
■ Range of motions
○ Behavior (How are they acting?)
■ Body odor
■ Facial expression
■ Anxiety

● Focused Assessment
○ After family history, nurse begins to ask specific questions about a problem

● Palpation:
○ Light Palpation = 2 fingertips in circular motion, 1 cm deep (0.39in)
○ Moderate Palpation = palmer surface of fingers of the dominant hand over the structure
■ 2 cm deep (0.4-0.75 in)
○ Deep Palpation = extended fingers of the nondominant hand placed over the fingers of the dominant hand
■ 2-4 cm (0.75 to 1.5in)
○ Fremitus (palpable vibration) and Crepitus – use palpation technique
○ Fremitus - palpation
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,● Percussion:




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, ○ Direct
■ Tapping the body with fingertips of the dominant hand
■ Used for sinuses
○ 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
○ Indirect
■ Hyperextended middle finger - tap on it with dominant hand
■ most common percussion for abdomen
Patient is having an enlarged thyroid gland. What technique to use?

● Percussion Sounds:
○ Tympany: loud, drumlike tone
○ Resonance: loud, low pitch - (normal lungs)
○ Hyperresonance: abnormally loud - (emphysema, COPD)
○ Dullness: high pitched, soft - (organs)
○ Flatness: high pitched, soft - (muscle, bone)

● Auscultation***
○ Bell - low frequency (used to hear heart murmurs, thyroid glands: normal you hear nothing; hold breath ,
carotid arteries => listening for bruits or swishing sounds )
○ Diaphragm - high pitched sounds (lungs and heart)
○ 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
○ Temperature
○ Pulse
○ RR
○ BP
○ Pain

● Korotkoff’s Sounds
○ Phase 1 - systolic, first faint sound
○ Phase 5 - diastolic, absence

● Inspect skin - perspiration is normal, cyanosis, pallor, erythema, jaundice
○ Eccrine gland: made up of water and salts
○ 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
■ B.O. at puberty
● Patchy and depigmented areas over face, neck, hands, feet = vitiligo (lighter skin tone)
● Wood’s Lamp = fungal infection
● Goniometer: measures the degree of joint flexion and extension
● Skinfold calipers: measures the thickness of subcutaneous tissues
● Otoscope: check the ear.
● Palpate skin using DORSAL hand to check for skin temperature.
○ Temperature increased = infection, hyperthyroidism

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, ○ Temperature decreased = hypothyroidism (what are the signs and symptoms? Select all that apply.)
○ Differences in temperature bilaterally = lack of circulation
○ NORMAL = skin is smooth, firm, even
○ SHOULD NOT report discomfort/pain
○ Dry lips = dehydration
○ Decreased skin turgor = dehydration
○ Skin turgor below clavicle and medial wrist
○ Older patients, skin tenting
● Edema - decreased skin mobility caused by an accumulation of fluid in intracellular space
○ +1 - 2 mm
○ +2 - 4 mm
○ +3 - 6 mm
○ +4 - 8 mm
○ Left­sided heart failure → Peripheral edema with no infection
● Pressure ulcers
○ Stage 1 - intact skin
○ Stage 2 - into epidermal skin layer
○ Stage 3 - subcutaneous tissue
○ Stage 4 - bone, muscle
● When palpating lesions use thumb and index finger
● Cancer Lesions (ABCDE)
○ Asymmetry
○ Border Irregularity
○ Color Variation
○ Diameter > 6 mm
○ Evolving

● Inspect Scalp and Hair
● Small amount of dandruff
● Assess texture of hair
● See if any lesions
● Pediculosis capitis = head lice

● Assessment of the Nails
○ NORMAL nails = well groomed, clean, convex curve, smooth, firm
○ Cap refill < 3 seconds
○ Clubbing = hypoxia, impaired peripheral tissue perfusion
○ Schamroth technique: a test to see the “diamond” when the fingernails are normal
○ Spoon nails = concave, usually due to iron deficiency
○ 160 degrees = normal
○ Greater than 160 = Clubbing
○ Less than 160 = curved nail
○ Onycholysis = trauma, infection of the nails

OLDCART & ICE
O = Onset L = Location D = Duration C = Characteristics A = Aggravating Factors R = Relieving Factors T = Treatment&I =
Impact on ADLs C = Coping Strategies E = Emotional Response Figure
7.4 Documentation of the Symptom—Cough, with OLDCART & ICE. OLDCART & ICE
Acronym Symptom: Cough
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