N524 exam claude

method skin assessment

inspection and palpation. general survey and continue throughouut exam use good lighting expose only the area being examined and wear gloves if lesion or lice are present

inspect skin assessment

color, vascularity, lesions nails, hair and scalp. Palpate (temp, moisture, turgor, texture,

expected (charting wordings) skin assessment

skin pink, warm, dry and intact w/ elastic turgor, no lesion, mucous membranes moist, intact and pink

erythema

redness from dilating superfical vessels (fever, imnflammation, injury, allergy) in darker skin check for warmth

cyanosis

blue or grey tinge form poor oxygenation, check lips, nail beds, ears and mouth

jaudice

yellow from elevated bilirubin. look at the sclera first and in darker skin at palms, soles, oral mucosa

pallor

anemia or shock. in darker skins it looks ashen grey or yellow

bleeding in skin: ecchymosis

bruiise. blood in subcutaneous tissue

petechiae

small hemorrhagic spots from capillary bleeding

turgor

lift a fold at the sternum or under the clavicle. it should snap back. solw return suggest dehydration (also normal decreased elasticity in older adults. difficulty lifting the folds may mean edema

diaphoresis

excessive persiration

nails

convex about 160 degrees at base, smoot, firm base

hair assessment

alopecia, hirsutism. Nits stay attached to the hair shaft, unlike dandruff or lint

melanoma ABCDEs

asymmetry, border uneven, color varied, diameter greater than 6mm, evolving

age variations

newborns have jaundice, milia and lanugo, older adulys have wrinkles, dryness, and decreased turgor

edema

excess fluid in tissue, swelling w/ taut, shiny skin. if pressing leaves indentiation it is the pitting form

causes of edema

overhydrated, heart failure, kidney failure, truama, peripheral vascular disease. fluid voume excess can cause height gain

common sites of peripheral edema

around eyes, finders, ankles, and sacrum

1+ edema

2mm

2+ edema

4mm

3+ edema

6mm

4+

8mm or more

peripheral pulses sites

carotid, brachial, radial, femoral, popliteal, dorsalis (pedal) and posterior tibial

pulse scale 0

absent

pulse +1

diminished weaker than expected

pulse +2

normal

+3 pulse

bounding

capilary refill

squeexe nail until blanches, release and count, should be under 3, over 3 suggest poor perfusion edema or low cardiac output

peripheral vascular disease symptoms

pale, cool, shiny skin w/ brown discoloration hairless legs, thickened toenails

cardiac assessment history

chest pain, palpitations, dizziness, ankle swelling, number of pillos, meds, family history, smoking, diet, exercise

apical impulse site

4th to 5th intercostal space, left midclavicular line

thrills (heart)

adnormal, fine rushing vibrations

auscultation sites heart

aortic, pulmonic, Erbs point, tricuspid, mitral

S1 Lub

closure of mitral and tricuspid valves, loudest at the apex and tricuspid area

S2 dub

closure of aortic and pulmonic valves, loudest at base

S3 (lub-dub-dee)

near mitral area pt left side. normal in children and ypun adults abnormal in middle aged older adults

S4 dee lub dub

right before S1, normal in older adults but adnormal in children and adults