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Health Assessment
Vocab
| Question | Answer |
|---|---|
| Respiratory Crackles | Wet, popping sounds during inspiration that are created by air moving through liquid or collapsed alveoli snapping open. |
| Rebound Tenderness | Increase in pain when deep palpation over tender areas is released. |
| McBurney's Point | The spot where the appendix can be located for examination. An imaginary line is drawn between the body prominence of the anterior hip bone and the belly button. It is about 1/3 of that line from the hip prominence. |
| Iliocecal Valve | The muscular sphincter where the end of the small intestine and the beginning of the large intestine meet. |
| Romberg Test | This is a tool that assess's a patient's balance. The patient stands with their feet together, hands at their sides, and eyes closed. While guarding them against falling, the nurse assesses how much the patient sways. Minimal swaying is expected. Excessive swaying, losing balance, or falling is an abnormal finding. |
| Psychomotor Function | The ability for skeletal muscles to move when the brain activates them. |
| Cognition | Mental processes such as thinking, learning, and remembering. |
| Bruit | Pulsing, blowing sounds caused by turbulent blood flow. |
| Otoscope | A tool used to examine the ears. |
| Edema | Excessive fluid accumulation within interstitial/intracellular spaces. |
| BMI ranges | Over or equal to 25 is overweight. Over or equal to 35 is obese. Under 18.5 is underweight. Between 18.5 and 25 is healthy. |
| Clinical Questions About the Skin | Do you have a history of allergies, rashes, or other skin problems? Do you have any problems with or have you noticed at changes with your skin or nails? Do you currently have any itching, bruising, lumps, rashes, scars, open sores, or skin lesions? How do you care for you skin and nails? Do you or a family member have a history of skin cancer? Do you perform a self assessment of moles and lesions? |
| Skin allergy, rash, problems follow up questions | When did they start? What did they look like? Where were they located? What do you think was the cause of their appearance? Did you seek medical treatment? Did treatment help them heal or go away? |
| Problems or changes in skin and nails follow up questions | When did the changes start? What do you think was the cause of the change in the appearance? Did you seek medical treatment? Did treatment help the problem go away or reverse the change? |
| Itching, bruising, lumps, rashes, scars, open sores, or skin lesions follow up questions | How long has the condition been present? Have you sought medical treatment or taken measures on your own to reduce the discomfort? How severe or painful is it? Has the condition affected your daily routines of self-care activities, your hygiene, or your ability to function at work/home/socially? |
| Skin and nail care follow up questions | What is your bathing or showering routine? Do you use ointments and lotions? Do you use sunscreen? |
| History of skin cancer follow up questions | What kind of skin cancer? What was your relationship to the person who had skin cancer? |
| Mole and lesion self assessment follow up questions | How often do you do it? Where are they located? If identified, can you tell me about their color, size, shape, sudden appearance, tenderness, bleeding, or itching? |
| Expected Skin Variations | Hyperpigmentation (freckles, chloasma, solar lentigines, birth marks, tan lines) and hypopigmentation (old scars, vitiligo, stretchmarks) |
| Oriented x4 | Oriented to person Oriented to place Oriented to time Oriented to situation |
| Documenting Skin Lesions | Color Height: flat or raised Shape of lesions Size: measured in centimeters Location: single area or generalized Presence of drainage: note color and odor |
| Vascular Lesions | The result of blood leaking from blood vessels into the dermis. These lesions can occur because of trauma, infections or a disease process |
| Petechiae | Small pinpoint (1 to 3 mm) reddish-purple spots. Usually the result of infection or trauma. |
| Ecchymosis | Collection of blood in the dermis greater than 3 mm in diameter. Initially reddish-purple, but will change to blue or yellow during healing. Caused by trauma. |
| Purpura | Collection of petechiae and ecchymosis covering an area caused by infections or bleeding disorders. |
| Primary Lesions | The result of a specific triggering agent which causes a change to previously intact skin. |
| Macule | Small flat primary lesion (less than 1 cm diameter) area of pigmentation change. Examples/Causes are freskles, moles, measles, and scarlet fever. |
| Patch | Larger flat primary lesion (greater than 1 cm diameter) area of pigmentation change. Examples/causes are vitiligo, birthmarks, and hormone changes |
| Papule | Small raised primary lesion (less than 1 cm diameter) area. Examples include warts, raised moles, and skin tags. |
| Plaque | Larger raised primary lesion (greater than 1 cm diameter) disc shaped area. Causes are psoriasis and eczema, |
| Wheal | Irregular area of edema on the skin caused by insect bites and allergic reactions. An example is hives. |
| Nodule | Small (less than 2 cm) raised, firm area arising from deeper in the dermis caused by melanoma or hemangioma |
| Tumor | Larger (greater than 2 cm) firm area arising from deeper in the dermis caused by lipoma and neoplasm |
| Vesicle | Small (less than 1 cm in diameter) superficial primary lesion filled with serous fluid and typically caused by varicella (chicken pox), shingles (typically follow a nerve pathway), and acute eczema |
| Bulla | Larger (greater than 1 cm in diameter) superficial primary lesion filled with serous fluid that can be caused by medication reactions. An example is blisters. |
| Pustule | Small (less than 1 cm in diameter) superficial primary lesion filled with purulent fluid. Examples include acne, and herpes simplex (cold sore) |
| Cyst | Encapsulated primary lesion arising from dermis or subcutaneous layer, filled with liquid or semi-solid fluid. Examples include cystic acne and sebaceous cysts. |
| Secondary Lesions | Evolved from their original status as a primary lesion. The passage of time has changed their characteristics. |
| Lichenification | Thickened and elevated skin caused by long-term, intense scratching or rubbing. Examples include chronic skin inflammation and psoriasis |
| Crust | Thickened and elevated skin caused by long-term, intense scratching or rubbing. Examples include scabs and eczema |
| Scale | Excessive shedding of keratin cells from the epidermis. Appears as dry or greasy small flakes that are white or silvery. Seen in conditions like eczema and psoriasis |
| Fissure | Straight line crack with abrupt edges that extends into the dermis. Seen in cheilosis (cracks in the corner of the mouth) and excessively dry hands or feet |
| Erosion | Shallow depression only present in the epidermis layer. Appears moist but without bleeding. Seen in varicella (chicken pox) and herpes simplex (cold sore) |
| Ulceration | Deeper depression involving loss of epidermis and dermis. May bleed. Seen in pressure injuries and poor blood flow to extremities |
| Excoriation | Loss of epidermis in linear crusted areas. Seen in abrasions and scratching |
| Potentially malignant lesions | Changes to the skin surface that can indicate the presence of skin cancer. |
| ABCDEs of skin cancer | Assymetry: Two halves of the lesion do not look the same. They are not a simple round circle or an oval shape. Border: The Lesion has an irregular outline (notching, scalloping, jagged edges, or blurred and vague boundries). Color: Color variation within the lesion. Diameter: Diameter of the lesion greater than 6 mm (the size of a pencil eraser) at its largest dimension. Evolving: Lesions change rapidly in size, symptoms, or composition. |
| Ugly Ducklings | A method of assessing for possible malignant lesions in patients with many nevi. It is is the mole that looks or acts quite different from the client’s neighboring nevi. It may itch, burn, or bleed and its features stand out in stark contrast to others. |
| Nevi | Moles |
| Pressure Injury | Forms when local circulation is impaired to underlying tissue that is squeezed tightly over a solid surface, such as a bony prominence. Often located on the back or the side of the body. |
| Risks factors of pressure injuries | Limited ability to reposition Thinner skin (due to aging) Poor nutritional state, which affects healing Presence of moisture due to incontinence, wound drainage or perspiration Clients being pulled up or across the bed linens resulting in a friction injury. |
| Stage I Pressure Injury | Reddened area that does not blanch with pressure Texture different (firmer or softer) than surrounding tissue Temperature different (warmer or cooler) than surrounding tissue |
| Stage II Pressure Injury | Partial loss of dermis Shiny or dry ulcer with pink wound bed May present as intact or ruptured blister |
| Stage III Pressure Injury | Full thickness skin loss with damage or necrosis to subcutaneous tissue Subcutaneous fat may be visible Dead tissue may be present in the wound bed. |
| Stage IV Pressure Injury | Full thickness skin loss resulting in exposed bones, tendons or muscle Dead tissue may be present in the wound bed. |
| Monitoring Pressure Injuries | Measure injuries upon detection. Continue to measure weekly to monitor for healing or deterioration. Monitor for signs of infection and changes in the appearance. Note any drainage, redness, or necrosis. Assess the patient for fever, chills, and increased pain. |
| Preventing Pressure Injuries | Inspect the skin frequently. Reposition every 2 hours. Elevate the head of the bed no more than 30° to prevent a shearing injury. Remove sources of excessive moisture. Provide dietary supplements as necessary. Never rub a reddened area. |
| Shearing Injury | Occurs when someone slides downward in a bed or chair. |
| Documenting a Pressure Injury | Location Size Depth Appearance, including any drainage if applicable |
| Expected Body Temperature | The patient's skin should feel warm and be consistent across the body. It is expected for the weather to affect the temperature of extremities compared to the rest of the body. |
| Localized Hyperthermia | Indicate an alteration, such as an inflammation in a painful joint, trauma to the muscles or bones, infection, or sunburn. |
| Localized Hypothermia | associated with decreased blood flow to the limb, such as with a blood clot or disease that impairs blood flow. |
| Skin Turgor | the skin's ability to change shape and quickly return to normal |
| Checking Skin Turgor | On the side anterior of the chest near the collarbone, pinch a large fold of the patient's skin. Release the skin to see how long it takes for the skin to return to its original position. |
| Good Skin Turgor | The skin is easy to pinch and returns to its original position almost immediately. |
| Tenting | When the skin remains in an elevated position after being released during the skin turgor test. Indicated severe dehydration or significant weight loss. |
| Generalized Edema | Present on both sides of the body, caused by a central problem such as heart or kidney failure. |
| Localized Edema | Present in one location or area of the body, usually caused by trauma or infections. |
| Pitting Edema | when pressure on the affected area leaves a visible indentation in the skin. |
| Palpating for Pitting | Ese your thumb or index finger to apply pressure for 3 to 4 seconds to the edematous area. Inspect the area after you release the pressure. If the skin remains smooth without indentation, the edema is nonpitting. If an indentation in the skin is present, further assess the depth of the pit in millimeters to determine the severity. |
| Expected Nail Characteristics | The nails should be slightly curved or flat. Thickness should be uniform. It should be translucent and is typically a little lighter than the skin tone. The base edge at the cuticles should be smooth and rounded. So should the sides of the nail. Older adult's nails grow slower and thicker. The nails may be brittle, composed of peeling layers, or yellow. |
| Assessing Capillary Refill | Apply pressure to the edge of the nail for 5 seconds. Release the pressure and note the number of seconds it takes for the nail bed to return to the baseline color. It should not take longer than 2 seconds. |
| Brown Lines in 1 Nail | May be a sign of melanoma, especially if it shows up suddenly, keeps growing, or has irregular edges. |
| Bluish Tinged Nails | Indicates cyanosis and needs to be addressed immediately. |
| Whitish Nails | Indicated anemia |
| Clubbed Nails | Nails that are spongy, spoon-like in shape, and wider fingertips. Indicate congenital heart disease, inflammatory bowel disease, or other pulmonary diseases. |
| Jagged Nails | Usually caused by nail biting or brittle nails. |
Created by:
marinareagankhan