1
PA FINAL NOTES LATEST
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
, 2
PA FINAL NOTES LATEST
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
, 3
PA FINAL NOTES LATEST
• 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
, 4
PA FINAL NOTES LATEST
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)
PA FINAL NOTES LATEST
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
, 2
PA FINAL NOTES LATEST
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
, 3
PA FINAL NOTES LATEST
• 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
, 4
PA FINAL NOTES LATEST
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)
