midterm ha

• SYSTEMS


  • SKIN
  • HAIR AND SCALP
  • NAILS
  • HEAD/FACE
  • EYES AND VISION
  • NOSE AND SINUSES
  • EARS AND HEARING
  • MOUTH AND THROAT
  • NECK
  • CHEST - LUNGS
  • HEART
  • BREAST AND AXILLAE
• Skin


  The first line of defense
• Skin structures


  • EPIDERMIS: Thin layer composed of epithelial tissue
  • DERMIS: Thick deeper layer that contains blood vessels, lymphatic vessels, nerves, hair follicles and sweat and sebaceous glands
  • SUBCUTANEOUS: Innermost layer of the skin

  
• Skin functions


  • Protect tissues
  • Prevents water and electrolyte losses
  • Senses temperature, pain, touch and pressure
  • Regulates body temperature
  • Synthesis of vitamin D
  • Promotes wound repair
• Skin assessment


  • Inspect and palpate the texture
  • Observe for moisture content
  • Palpate the skin for temperature
  • Observe for skin lesions

  
• ABCDE mnemonic for assessing suspicious lesions

  A = Asymmetry

  B = Border integrity

  C = Color variation

  D = Diameter greater than 0.5cm

  E = Evolution (changes over time)
• Abnormal skin findings


  • Café-au-lait spots
  • Cherry angiomas
  • Papular rash
  • Port wine hemangiomas
  • Pruritus
  • Purpuric lesions
  • Ecchymoses
  • Hematomas
  • Telangiectases
  • Urticaria
  • Vesicular rash
• Hair


  Formed from keratin
• Hair assessment


  Inspect and palpate the hair over the patient's entire body noting distribution, quantity, texture and color

  Check for patterns of hair loss and growth

  Inspect the scalp for erythema, scaling and encrustation
• Abnormal hair findings


  • Alopecia: Hair loss

  Hirsutism: Excessive hair in women
• Nails


  Check for color, thickness, shape and curvature of nails and other abnormalities like erythema, swelling and scaling

  Check for presence of calluses and corns

  Note for texture and capillary refill
• Abnormal nail findings


  • Beau's lines

  Clubbing

  Koilonychia

  Onycholysis

  Terry nails
• Head/Face assessment


  Size and shape, presence of trauma and bruise

  Pediatrics: Anterior and posterior fontanelles

  Nodules and depression

  Face: Note for facial expression, symmetry of facial features, abnormal movements, lesions and hair distribution
• Eyes and vision health history


  Determine patient history or chief complaint

  Ask if patient wears corrective lenses

  Obtain past medical history, especially disorders that may affect vision

  Determine medications taken or applied in the eyes

  Ask how vision impairment affects daily activities and assess support system
• Eyes and vision assessment

  • Inspect the external eye structure

  Inspect the cornea and assess corneal sensitivity

  Evaluate each iris for size, color, shape

  Examine pupils for equal size, shape and reactivity

  Test for visual acuity
• Abnormal eye and vision findings

  • Decreased visual acuity

  Diplopia

  Discharges

  Pain

  Periorbital edema

  Ptosis

  Strabismus

  Vision loss

  Visual floaters

  Visual halos
• Nose and sinuses


  Nose acts as sensory organ for smell, filters, warms and humidifies inhaled air
• Nose and sinuses assessment

  • Inspect mucosa for redness, swelling, growth and discharges and nasal polyps

  Inspect nasal septum for deviation

  Palpate the external nose for tenderness

  Palpate the maxillary and frontal sinuses for tenderness
• Ears and hearing assessment


  Inspect the auricles for color, texture, symmetry of size, position and angle

  Palpate the auricles for texture, elasticity and areas of tenderness

  Test hearing acuity

  Note discharges for color, smell, consistency

  Inspect the external ear canals for cerumen and inflammation, scaling, foreign bodies and lesions
• Abnormal ear and hearing findings

  • Earache

  Hearing loss (conductive or sensorineural)

  Otorrhea (drainage from the ear)
• Mouth and throat assessment

  Inspect the lips, inner mucosa, buccal mucosa, teeth, gums, tongue

  Palpate the tongue and floor of the mouth

  Inspect the tonsils

  Assess gag reflex
• Neck assessment


  Inspect for color and presence of lesions

  Palpate the thyroid, neck muscles, lymph nodes, trachea
• Chest assessment


  Inspection, palpation, percussion, auscultation of the lungs
• Heart assessment


  Auscultate and note rate, rhythm of the heart sounds, listen to abnormal heart sounds (murmur)

  Percuss the position and boundaries of underlying structures
• Breast and axillae assessment

  Inspect the breast, areola, nipple

  Palpate the breast and lymph nodes masses

  Palpate the axillary lymph nodes

  Note color, lesions, masses and hair distribution in the axillae
• Methicillin-Resistant Staphylococcus aureus (MRSA) risk factors

  • Having an invasive medical device
  • Residing in a long-term care facility
  • Presence of an MRSA-positive person in the facility
• Nursing History: Present Health Concern

  • Body odor problems
  • Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation)
  • Changes in lesion appearance
  • Feeling changes (pain, pressure, itch, tingling)
  • Hair loss or changes
  • Nail changes
• Client Preparation


  1. Ask the client to remove all clothing and jewelry

  2. Have the client sit comfortably

  3. Ensure privacy

  4. Maintain comfortable room temperature
• Equipment for Skin, Hair, and Nail Assessment

  • Gloves
  • Examination light and penlight
  • Mirror for client's self-examination of skin
  • Magnifying glass
  • Centimeter ruler
  • Wood light
  • Examination gown or drape
  • Assessment Tool 14-1, Braden Scale For Predicting Pressure Sore Risk
  • Assessment Tool 14-2, PUSH Tool to Measure Pressure Ulcer Healing
• Skin Assessment: Inspection


  • Distinctive odor
  • Generalized color variations
  • Skin breakdown
  • Primary, secondary, or vascular lesions
• Skin Assessment: Palpation


  • Lesions
  • Texture
  • Temperature and moisture
  • Thickness of skin
  • Mobility and turgor
  • Edema

  
• Pressure Ulcer Risk Factors


  • Perception
  • Mobility
  • Moisture
  • Nutrition
  • Friction or shear against surfaces
  • Tissue tolerance decreased
• Pressure Ulcer Risk Reduction #1

  1. Inspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document

  2. Bathe with mild soap or other agent; limit friction; use warm, not hot, water; set bath schedule that is individualized

  3. For dry skin: use moisturizers; avoid low humidity and cold air

  4. Avoid vigorous massage
• Pressure Ulcer Risk Reduction #2

  1. Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point

  2. Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient

  3. Refer incontinence condition to primary care provider

  4. Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products
• Scalp and Hair


  • General color and condition, cleanliness, dryness or oiliness, parasites, and lesions
  • Amount and distribution of scalp, body, axillae, and pubic hair
• Nail Assessment


  • Nail grooming and cleanliness, nail color and markings, shape of nails
  • Texture and consistency, capillary refill
• Nails Risk Factors


  • Nails in moist environment, especially walking in damp public locales or continuously wearing closed shoes; excessive perspiration
  • Nail injury, trauma, or irritation
  • Repeated irritation (especially water, detergents)
  • Immune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medications
  • Skin conditions such as psoriasis or lichen
  • Some trades or professions
  • Contagion from one digit to another or one person to another
  • Possibly family predisposition
• Capillary refill assessment


  Assesses blood flow to the peripheral tissues
• Hair color and texture

  Individuals of African American descent often have very dry scalps and dry, fragile hair
• Pressure Ulcer Stages


  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Unstagable