Health Assessment Exam 2 Overview

Excoriation

Abrasion or scratch

Striae

• Commonly seen in obesity or pregnancy or areas of rapid growth

• Striae generally fade or appear more silvery colored over time

• Connective tissue is damaged

Bruising

Does not blanch, flat. Can be indicative of abuse when found in certain areas.

Erythema

a superficial reddening of the skin or mucous membranes caused by increased blood flow (hyperemia) in the small surface capillaries

Bull’s eye rash

• Due to tick bite

• Lyme disease is a concern

• Is a papular task

Urticaria

Swollen, itchy area

Wheal

Elevated, irregular shaped area of subcutaneous edema, insect bite

Hives

May be a sign of a Type 1 allergic reaction, anaphylaxis, and can be followed by wheezing and respiratory arrest

Benign

Noncancerous

Malignant

Cancerous

Metastine

Spreads

Alopecia

Hair loss in multiple round patches

Autoimmune disorders, anemic conditions, nutritional deficiencies, radiation or antineoplastic treatments

Alopecia Areata

Chronic inflammatory disease of hair follicles

Unknown cause, believed to be autoimmune disorder, metabolic disease, and stressful events

Multiple round patches of hair loss

Hirsutism

Unwanted hair growth in women

Can be related to hormonal changes or PCOS

Basal Cell Carcinoma

Most common form of skin cancer, nodules pigmented lesion with depressed center and rolled borders and/or central ulceration in areas of sun of UV light exposure

Squamous Cell Carcinoma

• 2nd most common skin cancer

• Red, scaly patch with sharply demarcated border

• Lesion is soft, mobile, and slightly elevated and matures to a central ulcer with surrounding redness

Pediculosis

Head lice

Congenital Dermal Melanocytosis

• Due to increased melanocytes

• Usually disappears by age 1-2

• Irregular or oval bluish/greenish patches usually on back or buttocks

Nevus Simplex or “Stork Bites”

• Permanent dilation of small blood vessels in the base of the neck

• Usually disappears by 5 years of age

Lanugo

Silky body hair on newborns

Acne is a..

pustule: elevated, superficial, filled with purulent fluid

Blanching

Press on skin with one finger and skin turns white, then color returns rapidly when finger is raised from skin. Indicates good perfusion

Stage 1 Pressure Injury

• Skin is intact

• Nonblanchable redness

Stage 2 Pressure Injury

• Partial thickness

• Skin is not intact

• Shallow open ulcer with pink wound bed

Stage 3 Pressure Injury

• Even deeper

• Full thickness skin loss

• Subcutaneous fat may be visible

Stage 4 Pressure Injury

• Full thickness

• Bone, tendon, or muscle are exposed

• Slough or eschar may be present in the wound bed

Unstageable Pressure Injury

• Pressure ulcers that are covered with slough or eschar

• Must remove slough and eschar to stage

• You must be able to visualize the wound bed to stage a pressure injury

Slough

Loose, whitish yellow drainage

Eschar

• Dead tissue

• Dark, firm scab-like tissue

Deep Tissue Injury (DTI)

• In area that would be at risk for pressure injury

• Dark purple or maroon area on INTACT skin

• Can be confused with a bruise

Rheumatoid Arthritis

Bone on bone

Chronic inflammatory, autoimmune disease

Usually begins over weeks to months

Joint involvement is usually bilateral

Morning stiffness lasts more than 30 minutes

Osteoporosis

Brittle bone disease

Bones become porous due to a loss in bone mass/density

Loss of bone height and decreased bone density

Silent disease - occurs without signs or symptoms

Osteoarthritis

Degenerative joint disease

Progressive breakdown and loss of cartilage in one or more joints

Caused by wear and tear and trauma

Joint edema, aching

Morning stiffness lasts less than 30 minutes, decreases with movement

Rheumatoid arthritis deformities

• Ulnar deviation

• Swan-neck

• Boutonniere

Osteoarthritis deformities

• Herberden nodes

• Bouchard nodes

Gout

Key symptom is severe pain in the great toe, edema, tophi. Form of arthritis that develops from an increase in drum uric acid causing crystals to deposit in one or more joints.

Orthostatic hypertension

Usually associated with fluid volume deficit

Pitting edema

When you press down with the pad of your finger, an indent is left. How fast does indent resolve? How deep is the pit?

Pitting Edema Scale: 1+

Barely perceptible pit, 2 mm

Pitting Edema Scale: 2+

Deeper pit, rebounds in a few seconds, 4 mm

Pitting Edema Scale: 3+

Deep pit, rebounds in 10-20 seconds, 6 mm

Pitting Edema Scale: 4+

Deeper pit, rebounds in >30 seconds, 8 mm

Aortic space

2nd ICS RSB

Pulmonic space

2nd ICS LSB

Erb’s point

3rd ICS LSB

Tricuspid space

4th ICS LSB

Mitral space

5th ICS MCL

S3

• Ventricular gallop

• Fluid volume overload

• Rapid filling against the ventricle wall

• During diastole

• Can be normal in children and pregnant women

S4

• Noncompliant or stiff ventricle

• Rush of blood heard with atrial contraction against the ventricles after atrial contraction

• Occurs just before S1, about 0.2 seconds before

Heart rate of 40-60bpm

AV Node in action. Impaired electrical pulse conduction from the SA node.

Heart rate of 20-40 bpm

Left and right bundle branches in action

Right Ventricular Failure

RV can no longer contract effectively. Causes include hypertrophy from pulmonary HTN or necrosis from a myocardial infarction. Blood flows back into the inferior and superior vena cavae

RHF Symptoms

Fatigue, increased peripheral venous pressure, ascites, enlarged liver and spleen, may be secondary to chronic pulmonary problems, distended jugular veins, anorexia and complaints of GI distress, weight gain, dependent edema.

RHF Key Signs

• EDEMA

• Hepatomegaly

• Jugular distension

• Ascites

Left Ventricular Failure

LV can no longer contract effectively due to increased workload. Causes include aortic stenosis, hypertension, and myocardial infarction. Blood backs up into the LA and eventually into the lungs causing pulmonary edema.

LHF Symptoms

Fatigue, SOB, orthopnea, dyspnea of exertion, displaced apical pulse and palpable thrill, S3 heart sound, systolic murmur, crackles in the lungs

LHF Key Signs

• LUNGS

• Crackles

• Extra fluid in the lungs

• Cyanosis

• Dyspnea

Arterial Insufficiency

• Any condition that slows or stops the flow of blood through arteries

• Cooler skin temperature

• Minimal or no edema

• Dependent rubor, diminished/absent pulses, long cap refill

Venous Insufficiency

• Lower leg edema present

• Skin may feel warm or hot

• Pain is aching or cramping

Deep Vein Thrombosis

When a thrombus (clot) develops within a vein. Can become an embolus and travel into the lungs - pulmonary embolism.

GERD (Gastroesophagel Reflex Disease)

Heart burn

PUD (Peptic Ulcer Disease)

Open sores on the inner lining of the stomach.

Kidney stones

Nephrolithiasis

Liver cirrhosis signs and symptoms

• Jaundice of eyes or skin

• Excess bilirubin

• Distention

• Ascites

Yellow/green vomitus

Bile duct obstruction

Feces smell in vomitus

Intestinal obstruction

Stomach contents in vomitus

Acute gastritis

Why must auscultation come before palpation in GI?

Palpation can change bowel sounds

Ascites

Extra interstitial fluid in the peritoneum. Found in the spaces around the cells. Has leaked out of the cells. One cause could be kidney disease.

Normoactive bowel sounds

Irregular, high pitched gurgles or clicks that should be noted 5-35 times per minute

Hypoactive bowel sounds

1-4 sounds per minute, lower in pitch

Hyperactive bowel sounds

More than 35 sounds per minute. High pitched sounds; borborygmi.

Borborygmi

Rumbling, growling, or gurgling sounds produced by the movement of gas, fluids, and food through the stomach and intestines.

Hypoactive bowel causes

Mechanical obstruction, bowel obstruction, paralytic ileus, NPO

Hyperactive bowel causes

IBS, bacterial infection, Chron’s, stomach bug

Expected upon percussion of abdomen

Tympany in all quadrants

McBurney’s Point

A point of specialized tenderness in acute appendicitis between the umbilicus and the right anterior superior iliac spine. Positive if there is rebound tenderness.

Incontinence

Involuntary loss of urine

Stress incontinence

Increased abdominal pressure that is placed on the bladder. Coughing, laughing, sneezing. Most common type of urinary incontinence. Can also be caused by physical activity and pregnancy.

Urge incontinence

Sudden strong urge to void. Muscles of the pelvic floor or urethra muscles are weak. EX: Diabetes mellitus, stroke, CVA

Overflow incontinence

Urine leaks from the bladder that’s always full. Can be caused by enlarged prostate. Doesn't fully empty.

Functional incontinence

Mobility issue. Difficulty ambulating. EX: arthritis

Firm, distended abdomen meaning

Can be a sign of impaction/blockage, ileus

Aortic Abdominal Aneurysm (AAA)

The client has a weakened and distended artery wall. Contents leak out into the cavity. Medical emergency.