Final Exam blueprint HA

Chapter 14: Skin, Hair, Nails

Correct Assessment Techniques and Findings for Skin Assessment

  • Subjective data:

    • Involves asking about the history of present health concerns, personal and family history, and lifestyle factors such as:
    • Sun exposure
    • Chemical exposure
    • Daily care

  • Physical Examination Preparation:

    • Client Preparation:
    • Client should remove all clothing, jewelry, nail enamel, artificial nails, and hairpieces (e.g., wigs, toupees).
    • Environmental Conditions:
    • The room must be a comfortable temperature with adequate light.
    • Equipment needed:
    • Gloves
    • Penlight
    • Magnifying glass
    • Centimeter ruler
    • Wood light

  • Key Findings from Examination:

    • Skin Assessment:
    • Inspect for:
      • Color
      • Odors
      • Integrity
      • Lesions
    • Palpate for:
      • Texture
      • Thickness
      • Moisture
      • Temperature
      • Mobility/Turgor
    • Hair Assessment:
    • Evaluate for:
      • Loss
      • Unusual growth
      • Cleanliness
      • Presence of parasites (e.g., head lice)
    • Nail Assessment:
    • Note the condition of:
      • Nail bed
      • Grooming
      • Color
      • Shape
      • Capillary refill
    • Assessment of Suspicious Lesions:
    • Use the ABCDE mnemonic to evaluate for potential skin cancer:
      • Asymmetry
      • Borders
      • Color
      • Diameter
      • Elevation

Effects of Aging on Skin, Hair, and Nails

  • Skin:
    • Becomes pale due to decreased melanin and dermal vascularity.
    • Feels drier due to decreased sebum and sweat gland activity.
    • Lost turgor can lead to sagging and wrinkling, particularly in facial, breast, and scrotal areas.
  • Hair:
    • Typically feels coarser and drier, grows slower, and thins.
    • Body and pubic hair decrease; however, women may notice increased terminal hair growth on the chin.
  • Nails:
    • Frequently appear thickened, yellow, and brittle.
  • General Concerns:
    • Decreased mobility may impair an older adult's ability to maintain hygiene.
    • Older adults are at a higher risk for pressure injuries due to fragile tissues.

Pressure Ulcers (Injuries)

  • Risk Factors:
    • Include prolonged pressure, friction or shearing forces, increased moisture (e.g., incontinence), and nutritional deficiencies (especially protein).
  • Assessment Tools:
    • Nurses should use standardized tools like the Braden Scale for predicting risk and the PUSH tool to measure healing.
  • Stages of Pressure Injuries:
    • Classified into stage 1 through 4 or as unstageable.
  • Risk Reduction Strategies:
    • Inspect skin at least daily.
    • Bathe with mild soap and warm (not hot) water; avoid vigorous massage.
    • Use careful positioning and turning techniques to avoid shear and friction.
    • Refer clients for nutritional supplementation or incontinence management as needed.

Chapter 15: Head and Neck

Correct Assessment Techniques and Findings for Head and Neck Assessment

  1. Collecting Subjective Data (Nursing Health History)

    • Pain Assessment: Use the COLDSPA tool:
    • Character
    • Onset
    • Location
    • Duration
    • Severity
    • Pattern
    • Associated Factors
    • Headache Impact: Utilize the Headache Impact Test (HIT-6) to determine impact of headaches on daily activities.
    • Present Concerns: Inquire about difficulty moving, lumps or lesions, difficulty swallowing, dizziness, blurred vision, or changes in hair/skin/nails.
    • Lifestyle and History: Ask about:
    • Tobacco and alcohol use
    • Use of helmets during recreational activities
    • Typical posture
    • Past medical history (including traumatic brain injuries)

  2. Preparing for the Objective Assessment

    • Client Preparation:
    • Instruct the client to sit upright and remain still; remove head/neck accessories (wigs, hats, jewelry, scarves).
    • Equipment Needed:
    • Stethoscope
    • Penlight
    • Small cup of water (for thyroid assessment)
    • Gloves (if drainage is present)

  3. Assessment Techniques and Findings

  • Inspection:
    • Head/Face: Inspect cranium for size, shape, configuration, and involuntary movements.
    • Neck: Observe the position, symmetry, and movement of neck structures, including cervical vertebrae and range of motion.
    • Emergency Findings (Stroke): Use the FAST tool:
    • Face drooping
    • Arm weakness
    • Speech difficulty
    • Time to call 911
  • Palpation:
    • Head: Palpate temporal arteries and temporomandibular joint (TMJ) for swelling, tenderness, or crepitation.
    • Neck: Palpate the trachea for midline position and thyroid gland for enlargement or masses.
    • Lymph Nodes: Systematically palpate common nodes:
    • Preauricular
    • Postauricular
    • Tonsillar
    • Occipital
    • Submandibular
    • Submental
    • Cervical chains (superficial, posterior, deep)
    • Supraclavicular nodes
  • Auscultation:
    • Thyroid: Auscultate for bruits only if enlarged.
  1. Older Adult Considerations
    • Facial Changes: Expect more prominent wrinkles due to decreased subcutaneous fat and a drawn-in mouth from mandibular bone resorption.
    • Vascular/Structural Changes: Temporal artery pulsations may feel weaker, and cervical curvature may increase (kyphosis).
    • Thyroid/Neck: Thyroid may feel more nodular or sit lower in the neck; range of motion may decrease if arthritis or osteoporosis are present.

Chapter 16: Eyes

Correct Assessment Techniques and Findings for Eye Assessment

  • Preparation and Equipment:

    • Explain to the client that close proximity with an ophthalmoscope will be necessary.
    • Standard equipment includes:
    • Snellen or E charts
    • Handheld near vision cards
    • Penlight
    • Opaque cards
    • Disposable gloves

  • General Routine Screening:

    • Test both distant and near visual acuity.
    • Evaluate gross peripheral vision using visual fields testing.
    • Inspect external structures:
    • Eyelids
    • Eyelashes
    • Position/alignment of eyeball in the socket
    • Inspect the bulbar conjunctiva, sclera, lacrimal apparatus, iris, and pupil.
    • Assess pupillary reaction to light.

  • Focused Specialty Assessment:

    • Perform:
    • Corneal light reflex test
    • Cover test
    • Cardinal fields of gaze test to evaluate extraocular muscle function.
    • Palpate the lacrimal apparatus; inspect palpebral conjunctiva, cornea, and lens.
    • Assess pupillary accommodation; use an ophthalmoscope for internal inspection (optic disc, retinal vessels, fovea, macula, anterior chamber).

Vision Check

  • Visual Pathway and Reflexes:
    • Assessment includes observing pupillary light reflex (direct and consensual) and accommodation.
    • Distant Vision: Use Snellen chart or E chart.
    • Near Vision: Use handheld screener or Jaeger test.
    • Important: Clients should wear glasses when testing near visual acuity.
    • Findings: The lens of the eye normally bulges to focus on close objects and flattens for distant vision.

Abnormalities

  • Cataracts:

    • Signs:
    • Clouding of the lens
    • Poor night vision
    • Yellowing of colors
    • Light sensitivity
    • Seeing "halos" around lights
    • Double vision in a single eye
    • Risk Factors:
    • Aging (most common over 65)
    • Smoking
    • Diabetes
    • Obesity
    • High blood pressure
    • Prolonged exposure to UV radiation

  • Presbyopia:

    • A common age-related condition impacting those over 45, resulting in decreased ability to focus on near objects.

  • Myopia:

    • Nearsightedness; sources note an "epidemic of myopia" among Eskimos.
    • High myopia increases risk for open-angle glaucoma.

  • Glaucoma:

    • Open-Angle: Characterized by blind spots and tunnel vision; risk factors include high eye pressure, family history, and being African-American over age 40.
    • Acute Angle-Closure: Symptoms include severe headaches, eye pain, nausea, vomiting, blurred vision, and eye redness; risk factors include age over 40 and East Asian or Inuit ethnicity.
    • Normal Tension: Risk factors include cardiovascular disease and Japanese ethnicity.

Other Considerations

  • Older Adult Considerations:
    • Beyond presbyopia, older adults may experience entropion (lid inversion), ectropion (lid rotation), pinguecula (yellowish nodules), and arcus senilis (white or bluish ring around the cornea).
  • Eye Trauma:
    • Signs of trauma include perforated globe, blood in the eye, white/hazy cornea, or irregularly shaped, fixed, or dilated pupil.
  • Muscle Abnormalities:
    • Includes strabismus (inward or outward turning of the eye), ptosis (drooping eyelid), and nystagmus (paralytic strabismus).

Chapter 17: Ears

Correct Assessment Techniques and Findings for Ears

  • Subjective Data Collection:

    • Ask the client about changes in hearing, drainage, pain, tinnitus (ringing), or dizziness/unbalance.

  • Physical Examination Techniques:

    • External Ear: Inspect and palpate the auricle, tragus, and lobule; palpate the mastoid process for tenderness.
    • Internal Ear (Otoscopic Exam):
    • Use an otoscope to inspect the external auditory canal and tympanic membrane (TM).
    • In adults, the canal is s-shaped, curving up/back initially and down/forward toward the inner part.

  • Normal Findings:

    • The TM should be visible; the canal should be clear or contain cerumen (earwax).
    • Note: Aging may cause the TM to appear cloudy or atrophied, making landmarks more prominent.

  • Abnormal Findings:

    • External Ear: Malignant lesions, otitis externa, microtia (small ears), tophi (gouty deposits), or polyps.
    • Canal: Excessive cerumen build-up or exostosis (bony growths).
    • Tympanic Membrane: Look for redness (acute otitis media), perforation, scarring, retraction, or cholesteatoma.

Hearing Assessment

  • Whisper Test: Used for general routine screening of hearing.
  • Tuning Fork Tests:
    • Requires a 512 or 1,024 Hz tuning fork.
    • Weber Test: Evaluates bone conduction to determine if hearing is equal in both ears.
    • Rinne Test: Compares air conduction (AC) and bone conduction (BC); in a normal ear, AC is heard longer than BC.
  • Romberg Test: Assesses clients' equilibrium using a watch with a second hand for timing.

Types of Hearing Loss

  • Conductive Hearing Loss: Occurs when something blocks or impairs sound waves through the external/middle ear (e.g., cerumen buildup, fluid).
  • Sensorineural (Perceptive) Hearing Loss: Results from damage within the inner ear; if anything is heard, air conduction is still longer than bone conduction (AC > BC).
  • Presbycusis: Common age-related sensorineural hearing loss that often begins with the inability to hear high-frequency sounds.
  • Risk Factors:
    • Aging
    • Heredity
    • Occupational/recreational loud noise exposure
    • Ototoxic medications
    • Illnesses with high fevers

Chapter 18: Mouth, Nose, Throat

Correct Assessment Techniques and Findings for Mouth, Nose, and Throat

  • Preparation:

    • Client should sit with head erect at eye level; explain the procedure.
    • Ask the client to remove any dentures, retainers, or orthodontic rubber bands.

  • Mouth Assessment:

    • Techniques: Involves inspection and palpation of lips, teeth, gums, and buccal mucosa.
    • Key Structures: Inspect openings of salivary glands (Stensen ducts on the buccal mucosa and Wharton ducts under the tongue).
    • Findings: Note any odor from the mouth; recognize physical variations (e.g., torus palatinus, bifid uvula, fissured tongue, fordyce granules).

  • Nose Assessment:

    • Techniques: Inspect and palpate the external nose for irregularities; check airflow by having clients breathe through each nostril while occluding the other.
    • Internal Inspection: Use otoscope/nasal speculum to view internal nasal cavity, septum, and turbinates.

  • Throat Assessment:

    • Techniques: Inspect the thorax (pharynx), including nasopharynx, oropharynx, and laryngopharynx.
    • Tonsil Grading:
    • 1+: Visible
    • 2+: Midway between tonsillar pillars and uvula
    • 3+: Touching uvula
    • 4+: Touching each other

Abnormalities

  • Candidiasis: Infection with Candida albicans, presenting as white, curd-like patches on the tongue or oral mucosa.
  • Oral Cancer: Detect through carcinoma of the lip/tongue, often appearing as non-healing ulcers. Early detection should be prioritized.
  • Leukoplakia: Thick, white patches on oral mucosa that are often precancerous and cannot be scraped off; hairy leukoplakia may appear on sides of the tongue.

Older Adult Considerations

  • Oral mucosa is often drier and more fragile in older adults, due to epithelial lining degeneration in salivary glands.
  • Older adults may show visible varicose veins on the ventral surface of the tongue.

Chapter 19: Thorax and Lungs

Correct Assessment Techniques and Findings for Thorax and Lungs

  • Inspection:

    • Color and Condition: Observe face, lips, and chest for signs of healthy oxygenation; inspect condition and shape of nails.
    • Configuration: Inspect anterior/posterior thorax for symmetry; abnormal findings include barrel chest (often in emphysema), scoliosis, and kyphosis (common rounded thoracic spine in older adults).
    • Breathing Patterns: Observe respiratory quality, client's positioning, and accessory muscle use.

  • Palpation:

    • Tenderness and Sensation: Palpate chest wall for tenderness, masses, or unusual sensations.
    • Fremitus and Crepitus: Assess for tactile fremitus (vibrations) and crepitus (air trapped under skin).
    • Thoracic Expansion: Palpate to ensure symmetric chest expansion, which may decrease with age but should remain equal.

  • Percussion:

    • Tone: Percuss to determine lung tissue density; normal lungs produce a resonant tone.
    • Abnormal Tones: Dullness found in pneumonia or pleural effusion; hyperresonance is typical in emphysema.
    • Diaphragmatic Excursion: Percuss to measure diaphragm movement distance during inhalation/exhalation.

  • Auscultation:

    • Listen