Assessment Techniques & Safety in the Clinical Setting (Skin, Hair, and Nails) | Chapter 8 & 13 + SHERPATH

what are the four methods of physical examination?

1. inspection

2. palpation

3. percussion

4. ascultation

describe a resonant sound

hollow or clear

describe a hyperresonant sound

low-pitch, booming

describe a tympany sound

airy thuds

describe a dull sound

muffled thud

describe a flat sound

a stop of sounds - solid

what sound should the student nurse expect from dense organs like the liver, spleen or heart?

dull sound

what sound should the student nurse expect from bones>=?

flatness sound

what sound should the student nurse expect from an adult lung?

resonance

what sound should the student nurse expect from a child lung?

hyperresonance

what sound should the student nurse expect from abdominal areas such as the intestines and stomach?

tympany

true or false: it is essential to clean the stethoscope between patients

TRUEEEEEEE

true or false: do not rush when performing a physical examination on patient as the student nurse is a beginner and the patient will usually understand and respect the honesty

true

what are the layers of the skin?

1. epidermis

2. dermis

3. subcutaneous tissue

true or false: vitamin D is produced through the skin

true

what is the functions of the sweat glands?

regulate temperature and fluid balance

what is the functions of the sebaceous glands?

lubricates the skin with sebum

review the many different functions of the skin…

1. protection

2. provide a barrier

3. perception - sensory surface

4. temperature regulation

5. identification

6. communication (e.g., blushing)

7. wound repair

8. absorption and secretion

9. production of vitamin D

what is the ABCDEs when assessing whether a mass is a mole or melanoma?

1. asymmetry indicated melanoma

2. border - melanoma have irregular, ragged, notched, or blurred border

3. color - melanoma have varying colors

4. diameter - the spot is larger than 6 mm across indicate melanoma

5. evolving - the mole changing in size, shape, or color which can indicate melanoma

true or false: individual have darker skin in areas where UV is higher to reduce the risk of sunburn and certain type of skin cancer but are prone to pigmentary disorders due to the skin having a higher level of melanocytes

true

keloid

overgrowths of scar tissues that extends beyond the original injury site

what is a population of individual have are at a higher risk for developing keloid?

individuals with darker skin tone

hyperpigmentation

darker patches of skin caused by excess melanin production

hypopigmentation

lighter patches of skin caused by reduced melanin production

true or false: keloid and hypo/hyperpigmentation can result from acne, inflammation, injury, or skin trauma

true

melasma

brown or grayish patches on the face due to overproduction of melanin

what are the causes of melasma?

radiation (UV, infrared), hormonal changes (e.g., most prominently during pregnancy), and genetic

review questions the student nurse need to ask the patient when doing a nail, hair, skin assessment…

1. are you experiencing any dryness on your skin?

2. are experiencing any itching on your skin?

3. are you experiencing any bruising on your skin

4. are you experiencing any rashes on your skin?

5. are you experiencing any hair thinning or loss recently?

6. are you seeing any changes to your fingernails or toenails

7. do you have a skin care routine? if yes, can you walk me through it?

8. are you on any type of medications right now?

should the student nurse begin with asking specific questions related to symptoms or open-ended questions related to background information?

open-ended background information then narrow down to symptoms

what should the student nurse ask patient to gain a background understanding of the patient problem and concerns when doing a hair, nail, skin assessment?

1. history (have the patient experiencing something like this before, are there any history of this occurring in their family, do they know of any trigger or things that make the conditions better, etc) —> anything that help the SN figure out the pathology of the conditions

2. new changes (patterns, trend, evolution)

3. old unaddressed concerns (what have been missed or ignored, or it can be very valuable to get the patient perception on the problem and what they think have been ignored)

4. exposure risks (kinda like history but more specific)

review the types of objective data the student nurse need to collect during a nail, hair skin, physical examination…

1. color (nail, hair, skin)

2. temperature (skin)

3. moisture (nail, hair, skin)

4. texture (nail, hair, skin)

5. thickness (nail, hair, skin)

6. edema (nail and skin)

7. mobility and turgor (skin)

8. bruising (nail and skin)

9. lesions (skin, hair nail)

10. shape and capillary refill (nail)

what should the student nurse look for when assessing the color of nail, hair and skin?

1. skin: overall tone, evenness, redness, pallor (unusually pale or lighter than general), cyanosis, jaundice

2. hair: pigmentation changes (e.g., graying0

3. nails: pink nail beds, cyanosis, or pallor

what should the student nurse look for when assessing the texture of nail, hair, and skin?

1. skin: smooth, rough, dry, or moist

2. hair: coarse, brittle, silky

3. nails: smooth surface or ridging

what should the student nurse look for when assessing the temperature of the skin?

warm or cool (assess via palpation)

what should the student nurse look for when assessing the moisture of the nail, hair and skin?

1. skin: dry, wet (due to sweating), oily

2. hair: dry, oily, or brittle

3. nails: dry or brittle

what should the student nurse look for when assessing the thickness of the skin, hair and nail?

1. skin: uniform or abnormal thickening in certain area, or thin

2. hair: thinning or thickening

3. nails: thickened or thin nail plates

what should the student nurse look for when assessing for lesions or abnormalities of the skin, hair, and nail?

1. skin: rashes, scars, moles, ulcers, etc

2. hair: scalp abnormalities (e.g., dandruff, lesions)

3. nails: nail deformities, pits, clubbing, or lines

what should the student nurse look for when assessing for mobility and turgor of the skin?

elasticity (used to assess for hydration)

what should the student nurse look for when assessing for capillary refill of the nail?

the time taken for the color to return after blanching

how does fear and anger influence skin color?

false pallor from peripheral vasoconstriction

how does embarrassment influence skin color?

false erythema from flushing in the face and neck

how does cigarette smoking influence skin color?

false pallor from vasoconstriction - smoking can also significantly damage blood vessels

why does the blood vessels vasodilate when it is hot and vasoconstrict when it is cold?

the blood vessels dilates so as to more heat can be lost and vasoconstrict to retain heat

how does prolonged elevation influence skin color

pallor (lack of oxygen), and coolness due to decreased arterial perfusion

how does dependent positions (limb hanging/dangling downward in term with gravity)

redness, warmth, and distended veins due to venous pooling to that area

how does immobilization and prolonged inactivity influence skin color?

pallor, coolness, pale nail beds, prolonged capillary filling time due to slowed circulation

what are some of the different point that the student nurse should take note on when documentary the patient’s history of present illness?

1. patient symptoms (what are they saying)?

2. onset, duration

3. aggravating/alleviation factors

4. character of symptoms (quality/severity)

5. associated symptoms (anything else reported alongside the chief complaint)?

6. medications/effort to treat (by the patient)

what are some of the factor the student nurse should make sure to ask the patient when documenting past medical and surgical history for the chest ahd lung?

1. thoracic trauma or surgery? (if yes, include dates of hospitalization)

2. use of home oxygen or ventilation-assitsting devices?

3. chronic pulmonary diseases (e.g., tuberculosis, bronchitis, emphysema, etc)?

4. chronic disorders (e.g., heart disease, cancer, etc)

5. testing (e.g., allergies, pulmonary function, tuberculin skin tests)

6. pneumonia?

7. flu vaccination

8. recent dental surgery?

when documenting family history, what are some potential risk factors the student nurse should acknowledge and ask the patient if they have a family history of such condition?

1. chronic diseases (e.g., tuberculosis, cystic fibrosis, ephysema)

2. allergy

3. asthma

4. atopic dermatitis

5. malignancy

6. bronchiectasis

7. bronchitis

8. clotting disorders (risk for pulmonary embolism)

9. connective tissue diseases

what factors should the student nurse ask the patient about their personal and social history/environment?

1. environmental hazard?

2. tobacco use?

3. nutritional status?

4. exercise tolerance?

5. regional or travel exposure? (ask recent travel?)

6. hobbies?

7. use of alcohol and/or illicit drugs?

A patient presents with dyspnea and lightheadedness. The nurse notes hypotension. On auscultation, the breath sounds are diminished, and on percussion, the lungs emit a dull tone. Which of these findings should the nurse document as history of present illness?

• dyspnea

• hypotension

• lightheadedness

• diminished breath sounds

• dullness over lungs

1. dyspnea

2. lightheadedness

true or false: objective data is not included in the patient history of present illness

true

A patient reports chest pain and tightness lasting for several hours at a time. On auscultation, the nurse notes wheezing on both expiration and inspiration. Which information would the nurse note as history of present illness?

• chest pain

• chest tightness

• wheezing on inspiration

• wheezing on expiration

• length of time that symptoms last

1. chest pain

2. chest tightness

3. length of time that symptoms last

HPI is based on information the patient provides about their symptoms, while signs are directly observed by the healthcare provider during a physical exam.

A patient reports shortness of breath after recent dental surgery. The nurse notes dullness on percussion, absent breath sounds, and pleural friction rub on auscultation. What information suggestive of a lung abscess would the nurse document as medical/surgical history?

• dental surgery

• shortness of breath

• dullness on percussion

• pleural friction rub

dental surgery (most likely infected materials has been aspirated into the lung)

A patient who reports smoking two packs of cigarettes a day presents with a cough and persistent wheezing. The nurse notes pleural effusion on the radiology report. What information related to lung cancer would the nurse document under personal/social history?

• cough

• smoking

• persistent wheezing

• pleural effusion

smoking

is head to toe general inspection or systematic inspection?

systematic inspection

general vs systematic inspection?

1. general: more jut glossing over what the nurse cna see and the inspection is very straightforward and simple

2. systematic: looking more specific to each areas of the body (doing a head to toes)

if a patient have a condition or illness related to an area of the body, the student nurse do a systematic inspection or a focused inspection after the general inspection?

focused inspection of the affected area

review some of the guidelines for inspection…

1. having adequate lighting (daylight or artificial)

2. conducting unhurried and careful inspection

3. exposing what you want to inspect

4. validating findings with patient

5. ensuring appropriate equipment is available

what is the first step to doing inspection on a patient?

perform a general inspection

which component is included as part of a systematic inspection?

1. observing patient front to back

2. checking patient for obvious injuries

3. assessing overall patient appearance

4. inspecting each body regiion from head to toe

review some of the palpation guidelines…

1. keep fingernails short to avoid hurting the patient

2. have warm hands and be gentle in approach to assist the patient in relaxing in order to obtain more accurate data

3. use correct palpation depth and the appropriate part of the hand to correctly identify findings without producing unnecessary discomfort to the patient

why body system does we need to do palpation after auscultation and not after inspection (IAPP and not IPPA)?

abdomen

what can the palmar surface of the fingers and finger pads be use to determine?

position, texture, size, consistency, fluid, crepitus, form of a mass, or structure

what can the ulnar surfaces (ball) of hand and fingers be used to determine?

vibration

what can the dorsal surface of the hand be use to determine?

temperature

what can the entire hand be used to determine

muscle strength (e.g., having patient gripping the full hand)

light palpation

pressing down to a depth of approximately 1 cm and is used to asses moisture, temperature, pulsation, tenderness, and superficial masses and lesions

deep palpation

pressing down to a depth of approximately 4 cm with one or two hands and is used to determine organ size contour

bimanual palpation

pressing down with both hands to entrap a mass or an organ (e.g., uterus, kidney, or large breasts) between the fingertips to assess size and shape

light palpation is best used to obtain which assessment data?

• uterine firmness

• moisture of skin

• liver shape and size

• distention of colon

moisture of skin

the ball of hand can be used to assess _________ and ________

vibrations; thrills

the forefinger and thumb can used to assess _______ and ______

nodules and tissue size

the tone heard from percussion is related to the density of the underlying ___________

tissue

tympanic (intensity, pitch, duration, quality, and example)

1. loud

2. high

3. moderate drumlike

4. gastric bubble (over the stomach)

hyperresonant (intensity, pitch, duration, quality, and example)

1. very loud

2. low

3. long

4. boom-like

5. emphysematous lungs

resonant (intensity, pitch, duration, quality, and example)

1. loud

2. low

3. long

4. hollow

5. healthy lung tissue

dull (intensity, pitch, duration, quality, and example)

1. soft to moderate

2. moderate to high

3. moderate

4. thud-like

5. over liver

flat (intensity, pitch, duration, quality, and example)

1. soft

2. high

3. soft

4. very dull

5. over muscle

resonance is usually heard over the ________

lung

dullness is usually heard over the __________ and _________

liver, heart

what are the different type of percussion?

1. immediate (direct)

2. mediate (indirect)

3. blunt or fist

immediate (direct) percussion

1. expose the patient’s skin

2. strike the finger directly against the patient’s body using short, sharp strokes of the fist or fingertips

mediate (indirect) percussion

1. expose the patient’s skin

2. use the middle finger of the dominant hand as a hammer, the middle finger of the nondominant hand is placed on the body and is struct by the dominant finger

3. keep other finger fanned out

blunt or fist percussion

1. expose the patient’s skin

2. place the nondominant hand on the body and strike with the fst of the dominant hand

what region of the body do we usually percuss using the immediate (direct) technique?

1. back (fist)

2. sinuses (fingers)

what region of the body do we usually percuss using the mediate (indirect) technique

1. thorax

2. abdomen

what region of the body do we usually percuss using the blunt or first technique?

1. liver

2. gallbladder

3. kidneys

true or false: for mediate percussion, avoid striking directly on the interphalangeal joint as they would dampen the sound

true

the nurse would expect to hear which tones when percussing the patient’s liver?

• tympany

• dullness

• resonance

• flatness

dullness

the nurse percusses the patient’s chest and notes a loud, low, hollow tone - the nurse notes this is an expected finding when assessing over which body area?

• bone

• upper liver

• lungs

• heart

what sound is expected when percussing over the muscle of the thigh?

• resonant

• flat

• tympanic

• dull

flat

the nurse is preparing to use the middle finger of the dominant hand to tap on the middle finger of the nondominant hand - which is placed on the patient’s chest - which type of percussion is the nurse using?

• direct

• indirect

• blunt immediate

indirect

which techniques help identify percussion tones?

• downward snap of the forearm

• slowly snapping back the wrist after striking

• striking with the fingertips

• alternately striking direct on and then distal to the interphalangeal joint

striking with the fingertips

auscultation involved listening for sounds produced by the body or organs within the body, usually the ___________, ___________, ____________, and _____________

heart; lungs; intestines; blood vessels

auscultation considerations

1. keep the eyes closed and block out environmental noises to help identify auscultation sounds

2. warm the stethoscope headpiece before placing it on the patient’s

3. friction from body hair rubbing against the stethoscope diaphragm could be mistaken for adventitious lung sounds (crackles)

4. make sure to clean the stethoscope between patients to avoid transmitting infection from one patient to another

what are some of the factors of auscultation sounds that the student nurse should look out for?

1. intensity

2. pitch

3. duration

4. quality

Which techniques help correctly identify auscultation sounds?

Select all that apply.

• Listening for the presence of sound

• Noticing the characteristics of sound

• Angling the stethoscope earpieces in the ear correctly

• Placing the stethoscope on the patient’s skin

• Auscultating over the patient’s gown

• Listening for the presence of sound

• Noticing the characteristics of sound

• Angling the stethoscope earpieces in the ear correctly

• Placing the stethoscope on the patient’s skin

What steps can the nurse take to isolate auscultation sounds and facilitate accurate assessment findings?

Select all that apply.

• Listen to one sound at a time

• Close eyes to focus on sounds

• Anticipate the next sound heard

• Block out environmental noises

• Distinguish sound from other sounds

• Listen to one sound at a time

• Close eyes to focus on sounds

• Block out environmental noises

• Distinguish sound from other sounds

The nurse auscultates to obtain which assessment information?

Select all that apply.

• Sounds produced by internal organs

• The sound of heart valves closing

• Expected movement of air or fluid through internal organs

• The temperature and texture of skin

• Distention or pulsation of the abdomen

• Sounds produced by internal organs

• The sound of heart valves closing

• Expected movement of air or fluid through internal organs