reviewer

• Conducting general survey


  Observation of the client's general appearance, level of comfort and mental status
• Appearance & mental status

  The general appearance and behavior of an individual must be assessed in relationship to culture, educational level, socioeconomic status, and current circumstances
• Overall impression of the client


  Requires your objective observation skills to assess the client's appearance, mobility, and body build
• Mental status exam


  1. Determine the client's emotional and cognitive functional statuses

  2. Assess information about the cerebral cortex function

  3. Assess validity of the subjective information provided by the client
• Vital signs (not invasive procedure)

  • Pulse (PR)
  • Respiration (RR)
  • Blood pressure (BP)
  • Temperature (temp)
  • Pain
• Ask the client if he or she has any pain
• No subjective report of pain
• Signs of distress and pain

  1. Observe posture

  2. Facial grimace

  3. Sad expression

  4. DOB

  5. Skin color
• Posture


  Erect and comfortable for age
• Gait


  Rhythmic and coordinated with arms and swinging side
• Appearance in relation to age

  Compare the client's stated age with his or her apparent age and developmental stage
• Body structure


  • Malnourished - children may be short for their age, thin, or bloated
  • Overweight & obesity - abnormal or excessive fat accumulation that presents a risk to WHO
  • Apple shaped - carry most of excess body fat around stomach
  • Pear shaped - carry most of their excess body fat around the hips, buttocks and thighs
  • Length of the limbs - distance from the middle fingertip of the left hand to the middle finger trip of the right hand (1:1)
• Body mass index (BMI)


  Weight (kg)/height (m2) - an inexpensive and easy screening method for weight category, underweight, healthy weight, overweight, and obesity
• Types of gait


  • Spastic gait - a stiff, foot-dragging walk caused by a long muscle contraction on one side
  • Scissors gait - Legs flexed slightly at the hips and knees like crouching, with the knees and thighs hitting or crossing in a scissors like movement
  • Propulsive gait - A stooped, stiff posture with the head and neck bent forward
  • Steppage gait - Foot drop where the feet hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal walking
  • Waddling gait - Duck like walk that may appear in childhood or later
• Physical deformities


  • Polydactyl - deformity in which hand has extra digit (fingers) (can also be in toes)
  • Syndactyly - 2 or more digits of fingers are fused
• Self care deficit


  Ability to perform certain daily functions related to health and well being
• Body odor and breath

  • Halitosis- bad breath
  • Keto breath - fruity scent as nail polish remover, sign of abnormally high ketones
  • Ketones - acid
  • Ketoacidosis- diabetic
• Facial features and expression


  • Facial features are symmetric with movement
  • Facial dropping - loss of facial movement due to damage of the nerve. (Bell's palsy or stroke)
  • Ptosis- drooping of the upper eyelid results from the damage of nerves that control the muscles of the eyelid
• Affect and mood


  • Mood - emotional of state mind or feeling
  • Affect - display of emotion
  • Level of consciousness - measurement of arouse ability response to the environment of stimuli
• Speech


  Slurred speech - a symptom characterized by poor pronunciation of words, mumbling, or a change in speed or rhythm during taking. (dysarthria) - glossopharyngeal (9th) & vagus (10th) cranial nerves
• Integumentary system


  Organ system consisting of the skin, nails and exocrine glands
• Skin


  • Largest organ of the body
  • Protects the underlying tissue and organs from microorganisms, physical trauma, ultraviolet radiations and dehydration
  • Thicker on the palms and soles
  • Vital roles in temperature maintenance

  
• Temperature maintenance


  • Regulates body temperature by cooling through heat loss by evaporation of perspiration
  • Conducting heat from the body through vasodilation
  • Body heat is conserved through lack of perspiration (Vasoconstriction of blood vessels)
• Epidermis (outer layer of skin)

  • Stratum corneum - consist of dead keratinized cells that render the skin waterproof barrier between the deep layers of skin from microorganisms or toxins from entering the body
  • Stratum lucidum - thin lighter appearing layer only present on the palms and soles
  • Stratum granulosum - skin cells containing components that contribute to the formation of the outer skin layer
  • Stratum spinosum - allows keratinocytes (cells that produce keratin) to mature
  • Stratum basale (stratum germinativum) - deepest layer only layer that undergoes cell division and contains ''melanin'' (brown pigment) and ''keratin- forming cells''

  
• Melanin


  Major determinant of skin color helps protect skin from Uv rays
• Dermis (inner layer of skin)


  • Well - vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings and lymph vessels

  
• Collagen


  Most abundant protein in the body providing skin structure and strengthening skin (elasticity and hydration)
• Glands in dermis


  • Sebaceous glands - attached to hair follicles, present over most of the body excluding palms soles
  • Sebum - oily substance that waterproofs the hair and skin
  • Eccrine sweat glands - located over the entire skin that secretes sweat and thermoregulation through evaporation of sweat from the skin surface
  • Apocrine sweat glands - associated with hair follicles in axillae, perineum (groin) and areola of the breast, non functional until puberty in women, linked with the menstrual cycle
• Subcutaneous tissue (hypodermis)


  • Loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles
  • Stores fat - energy reserve
  • Insulation- conserve body heat
  • Cushion - protect bones and internal organs
  • Vascular pathways -supply of nutrients and removal of waste products to and from the skin
• Hair


  • Consists of layers of keratinized cells, found over much of the body except for the lips, nipples, soles of the feet, palms of the hands
  • Thermoregulation by wicking sweat away from the body
  • Protects scalp, provides insulation, and allows self – expression
  • Nasal hair, auditory canal hair, eyelashes and eyebrows filter dust and other airborne debris
• Parts of the hair

  • Hair shaft - visible above the skin surrounded by hair follicle
  • Hair follicle - sheath of epidermal cells. The function is to grow your hair
  • Arrector pili muscles - attached to hair follicles which contract in response to cold or fright, decreasing skin surface area and causing the hair to stand erect
  • Hair bulb - forms the base of hair follicle, living cells divide and grow to build hair shaft
  • Hair papilla - at the base of hair follicle which contains blood supply for the hair
• Nails


  • Located on distal phalanges of fingers and toes
  • Hard, transparent plates of keratinized epidermal cells that grow from the cuticle
  • Protects the distal ends of the fingers and toes
  • Enhance precise movements of digits

  
• Parts of the nail

  • Lunula - crescent - shaped area located at the base of the nail
  • Eponychium - living tissue attached to the nail plate that protects the area between nail and epidermis from exposure to bacteria
  • Cuticle - nonliving tissue or dead skin cells
  • Hyponychium - skin under the free edge of the nail just beyond the distal end of the nail bed

  
• Rationale for physical assessment of integumentary system

  • Establish normal baseline data and to detect variations in appearance, asymmetry, color variations, size, and elevation
  • Changes in sensation may indicate vascular or neurological problems such as peripheral neuropathy related to DM or arterial occlusive disease
  • Some medication can cause photosensitivity reaction after sun exposure
  • Uncontrolled body odor or excessive or insufficient perspiration may indicate an abnormality with the sweat glands or an endocrine problem
  • Nail changes may be due to systemic disorders such as malnutrition and Iron- deficiency anemia
• Asians and Native Americans have mild to no body odor because of decreased sweat production. Caucasians and African Americans tend to have a strong body odor
• Nail changes


  • Bacterial infection - cause green, black, or brown nails
  • Fungal infections - cause yellow, thick, crumbling nails
  • Yeast infection - causes white color and separation of the nail plate from the nail bed

  
• Rationale for past health history

  • Current problems may be a recurrence of previous ones
  • Visible scars may be due to previous problems/treatments
  • Various types of allergies can precipitate a variety of skin eruption
  • Some skin rashes or lesions may be related to viruses or bacteria
• Rationale for family health history (skin cancer)

  A genetic component is associated with skin cancer, especially malignant melanoma
• Skin cancer types


  • Basal cell carcinoma - occurs in sun- exposed areas such as neck and face, appear as pearly or waxy bump, sore that heals and returns
  • Squamous cell carcinoma - occurs in sun - exposed areas, appear firm, red nodule, flat lesion
  • Melanoma - can affect any skin tone, large brownish spot with darker speckles like a mole that changes in color, size, texture, or that bleeds and irregular border

  
• Skin cancer prevention


  • Avoid sun during the middle of the day
  • Wear sunscreen
  • Wear protective clothing
  • Ensure that diet is adequate in vitamin B3 (niacin)
  • Examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions: Asymmetry, Border, Color, Diameter, Evolution (changes overtime)