General + Cognitive + Integumentary Assessment

crepitis

cracking, grating, or popping sound /feeling produced by air or bone rubbing

joints, subcutaneous tissue, lungs

where is crepitis found

superficial/light palpation

depressing skin 1 in w/ fingers

deep palpation

1-1.5 inch firm depression w/ hands

bimanual palpation

using to hands to trap, stabilize, feel an organ and used to assess size, shape, mobility, consistency. ex. used during pelvic exams

vibration palpation

using ball of hand

direct inspection

observing patient with just the naked eye

indirect inspection

observing patient using tools such as otoscope, penlight, speculum

mesomorphic

average build/body type

ectomorphic

tall and thin, fat poorly developed, bones protrude

endomorphic

short, stocky, most likely obese

fowlers

patient sitting upright at 45-60 degree angle, used when eating

semi-fowlers

patient reclining at 30-45 degree angle, promotion for lung expansion

dorsal recumbant

lying on back w/ knees bent and feet flat on bed

lithotomy

lying on flat w/knees bent and feet in stirrups

ABCT

appearance, behavior, cognitive function, thought process 

lethargic

drowsy, sluggish, can be aroused to voice or touch

obtunded

hard to arouse, confused, needs constant stimulation to stay awake

stupor

unconscious but can be aroused vigorously or by pain

coma

unconscious and unresponsive

confused

delirious

erythema/redness in light skin

bright red or pink

erythema/redness in dark skin

purplish, deeper browm, waxy undertone

cyanosis (low oxygen) in light skin

blue lips, nails, mucosal membranes

cyanosis (low oxygen) in dark skin

greyish, whitish, ashen tone 

pallor in light skin

pale, loss of rosy undertone (check nails and palms)

pallor in dark skin

ashen, gray, yellowish brown (check nails and palms)

jaundice in light skin

yellow sclera/skin (check sclera, lips, tongue)

jaundice in dark skin

yellow-brown sclera/skin (check sclera, lips, tongue)

bruising in light skin

blue, purple, green, yellow phases

bruising in dark skin

deeper dark brown, black, purple

inflammation in light skin

redness, swelling, warmth

inflammation in dark skin

swelling and warmth, may be easier to feel than touch

mental assessments

what is ABCT used for

forearm, sternum, forhead

where can you check turgor

primary lesions

macule, papule, plaque, nodule, wheal, vesicle, pustule

macule

flat, less than 1 cm, color change only (ex. freckle)

papule

raised, less than 1 cm, solid (ex. mole, wart)

plaque

raised, greater than 1 cm, flatter, formed by coalescing (merging into one) papules (ex. eczema)

nodule

solid, elevated, greater than 1 cm, deeper (ex. fibroma)

wheal

superficial, raised, temporary, irregular (ex. mosquito bite, hives)

vesicle

elevated, less than 1 cm, filled w/ clear fluid (ex. herpes simplex, veracella)

pustule

elevated, filled with pus (ex. acne, impetigo)

crust

dried exudate (serum, blood, pus) on surface (ex. scab after abrasion) 

scale

flakes of dead keratinized cells (ex. psoriasis, dandruff)

excoriation

self-inflicted superficial abrasion (scratches from itching)

linchenification

thickened, rough skin from chronic scratching (ex. chronic eczema)

keloid

hypertrophic scar w/excess collagen (ear piercing scar)

ABCDE

asymmetry, border, color, diameter, elevation + enlargement

skin/lesion assessments

what is ABCDE used for

secondary lesions

crust, scale, excoriation, linchenification, keloid

alopecia

loss of hair, common abnormalities of hair

nail thickening

when nails thicken, common abnormality of nails

onycholysis

separation of nail from bed, common abnormality of nails

koilonychia

spoon shaped nail, common abnormality of nails

clubbing

sign of chronic hypoxia, nail base greater than 180 degrees, common abnormality of nails

beau’s lines

horizontal grooves in nail, common abnormality of nails

dyschromia

nail discoloration (happens after chemo), common abnormality of nails

emergency appraisal

airways, breathing, circulation

flatness (percussion)

very dense tissue (muscle, bone). “flat” sound

dullness (percussion)

more solid tissue (liver, spleen, heart), "thud” sound

tymphany (percussion)

enclosed air (stomach, intestines, cheek), “drum-like” sound

resonance

part air and part solid (normal lung tissue), “hollow” sound

hyperressonance

more air than normal (infant lung, hyper-inflated lung), “blooming” sound