Physical Assessment Final Exam January 2019

Physical Assessment Final January 2019 Inspection technique (3): ● FIRST technique with general survey ● General survey: ○ Observing mobility / gait, physical appearance, general wellness/health, mood & behavior ( ...

Physical Assessment Final January 2019 Inspection technique (3): ● FIRST technique with general survey ● General survey: ○ Observing mobility / gait, physical appearance, general wellness/health, mood & behavior (facial expressions, interactions), mental status (observing patient’s body language and response when asking questions) ● Do it the SAME WAY every time → less likely to forget something ● Do not rush it, especially with anxious patients ○ Make sure the patient is comfortable ○ Temperature in the room is suitable for the patient ● Make sure that you have everything that you need → so that the patient has confidence in you ● Know normal vs abnormal when surveying appearance & symmetry ○ Compare ANYTHING that has a pair ○ Eyes- level, equal, is there eyelid drooping? ○ Smile- is there a droop? ○ Always compare the two sides to ensure that there is no abnormality between the two sides ● Listen for natural sounds ○ Abnormal sounds: wheezing, labored breathing, crepitus during ROM ● Detect abnormal odors: ○ CDIFF, alcohol on a patient, acetone / sugary breath ● Try not to assume anything ! → use critical thinking! ○ Ex: someone with low blood sugar or issues with hypoxia can appear intoxicated ● Know your normal values: ○ Blood pressure, HR, RR, O2 sats, temperature ○ For each age levels ■ Infants: must faster RR than elderly ________________________________________ Percussion technique (3) ● Types: ○ Direct percussion- tapping body with fingertips of dominant hand ■ For a small infant → direct percussion on the chest ■ Adult → on the sinuses on the face ○ Blunt percussion- place palm of nondominant hand flat against the surface and strike it with closed-fist dominant hand ■ Used to assess the kidneys → assessing for pain / tenderness (UTI) ○ Indirect percussion- most commonly used ■ Plexor = hammer or tapping finger ■ Pleximeter = device or surface that accepts the tap ● Sounds: ○ Intensity of amplitude: softness or loudness ○ Pitch or frequency: high or low (vibrations per second) ○ Duration: length of time ○ Quality: recognizable overtones or drumlike sounds ● Tympany- sound heard over stomach or intestines ○ Loud, high-pitched, drum-like tone ● Resonance- normal sound heard over lungs ○ Loud, low-pitched, hollow tone ● Hyperresonance- air trapped in lungs ○ Abnormally loud, low tone of longer duration than resonance ■ COPD, trauma or lung collapse ● Dullness- over solid body organs (liver) ○ High-pitched tone, soft and short ● Flatness- over solid tissue, muscle, or bone ○ High-pitched tone, very soft & shorter than dullness ■ Ex: ribs ________________________________________ Skin assessment (5) ● Life span considerations: ○ Infants and children ■ Newborn skin → covered with vernix caseosa ■ Infants have thin, soft, skin and free of hair ■ Milia and stork bites- common, harmless markings in newborns ■ Mongolian spots- gray, blue or purple spots in sacral and buttocks area ● Fade by age 3 ● Try not to confuse it with possibility of abuse → ask the parent “is this something that has been here since birth?” ■ Poor temperature regulation → do not secrete from glands ○ Pregnant female ■ Skin pigmentation increases → in areolae, nipples, vulva, perianal area ● Development of melasma and linea nigra down the abdomen ● Resolve itself after pregnancy ■ Hormonal changes→ cause oil and sweat glands to become hyperactive ● Acne worsens in 1st trimester ■ Hair may fall out during months 1-5 ○ Older adult ■ Skin elasticity decreases with aging ■ Sebum production decreases → causes dryness ● More prone to skin breakdown ■ Perspiration / sweating decreases ■ Decrease in melanin production → result in gray hair ■ Nails become thicker and more brittle due to decreased amount of circulation ■ Hair thins because of decrease of hair follicles ■ Liver spots, hyperpigmented freckles, increased amount of skin tags ● Psychosocial considerations: ○ Stressed induced illness: ■ Trichotillomania- hair twisting & pulling ■ Nail biting ■ Visible skin disorders in relation to self-esteem / body image ● Cultural and environmental considerations: ○ Socioeconomic status ■ Not able to go to the doctor because of finances ○ Home environment ■ Are they homeless? → if so, could be more likely to develop skin cancer due to outside exposure ○ Means of employment ■ If they work outside → important to know ■ Do not assume bad hygiene!! → could be from work ○ Changes in skin color → may be more difficult to detect in patients with dark skin ○ Dry skin does not necessarily indicate dehydration ○ Skin response to stressors differ from person to person ■ Autoimmune disorders ○ Differences in hair color and texture vary from different cultural groups ○ Prolonged immersion of hands in water can cause paronychia- reddened cuticles causing infection ○ Table 13.2 (variations) 31:28 ● Focused interview- questions related to: ○ Notice any smells / foul odors ○ Changes in color → oxygenation issues or perfusion ○ Sweating → fever, being in the sun too long, excessive sweating ○ Skin: ■ In general ■ Illness or infection ■ Symptoms, pain, behaviors ■ Age ■ External environment ○ Hair: ■ In general ■ Infants and children ○ Nails: ■ In general ■ Infants and children ■ Pregnant females ■ Older adult ● Color variations in light and dark skin ○ Pallor- loss of color in skin due to absence of oxygenated hemoglobin ■ Light skin: ● White skin loses rosy tones ● Yellow tone appears more yellow ■ Dark skin: ● Black skin loses its red undertones and appears ash-gray ● Brown skin becomes yellow-tinged ○ Absence of color- loss of pigment ■ Albinism- white/pale blond hair and pink irises ■ Vitiligo- very noticeable as patchy milk-white areas ■ Tinea- appears patchy areas paler than surrounding skin ○ Cyanosis- blue color in skin due to inadequate tissue perfusion ■ Light skin: ● Skin, lips, mucous membranes look blue-tinged; nail beds are blue ■ Dark skin: ● May appear a shade darker ● May be undetectable except for lips, tongue, oral mucous membranes, nail beds, and conjunctivae ○ Reddish blue tone- ruddy tone due to increased hemoglobin and stasis of blood ■ Light skin: reddish purple hue ■ Dark skin: difficult to detect; normal skin may appear darker in some patients ○ Erythema- redness of the skin due to increased visibility of normal oxyhemoglobin ■ Light skin: local inflammation and redness ■ Dark skin: hard to detect; inflammation appear purple or darker than surrounding skin ○ Jaundice- yellow undertone due to increased bilirubin ■ Generalized; visible in sclera, oral mucosa, hard palate, fingernails, palms of hands, and soles of the feet ________________________________________ Skin lesions (5) ● Primary lesions: ○ Macule and patch- flat, nonpalpable change in the skin color ■ Macule: Smaller than 1 cm ■ Patch: larger than 1 cm ○ Papule and plaque- elevated, solid palpable masses with a circumscribed border ■ Papule: smaller than 0.5 cm ■ Plaques: groups of papules that form lesions larger 0.5 cm ○ Nodule and tumor- elevated, solid, hard or soft palpable mass extending deeper into the dermis ■ Nodules: smaller than 2 cm ■ Tumors: may have irregular borders and are larger than 2 cm ○ Vesicle and bulla: elevated, fluid-filled, round or oval-shaped, palpable masses with thin, translucent walls and circumscribed borders ■ Vesicles: smaller than 0.5 cm ■ Bullae: larger than 0.5 cm ○ Pustule- elevated, pus-filled vesicle or bulla with a circumscribed border ■ Size varies ○ Wheal- an elevated, often reddish area with an irregular border caused by diffuse fluid in tissues ■ Size varies ○ Cyst- elevated, encapsulated, fluid-filled or semisolid mass originating in subcutaneous tissue or dermis ■ Usually 1 cm or larger ● Vascular lesions: ○ Ecchymosis- flat, irregular shaped lesion of varying size with no pulsation; does not blanch with pressure → BRUISE ■ In light skin: bluish, purple mark that changes yellow ■ Brown skin: varies from blue to deep purple ■ Black: darkened area ○ Hemangioma- bright, red raised lesion about 2-10 cm in diameter that does not blanch with pressure; present at birth or within few months of birth and typically disappears by age 10 ■ Cluster of immature capillaries ○ Cullen sign- periumbilical; could indicate internal bleeding in abdomen ○ Grey turner sign- flank area; could indicate bleeding into peritoneum, pancreatitis, etc. ○ Hematoma- raised, irregularly shaped lesion similar to ecchymosis except that it is elevated and looks like swelling ■ Caused by leakage of blood into the skin and subcutaneous tissue ○ Petechiae- flat, red or purple rounded “freckles”; approximately 1-3 mm in diameter; pinpoint lesions ■ Difficult to detect in dark skin and do not blanch ○ Purpura- flat, reddish-blue, irregularly shaped extensive patches of varying size ○ Port-wine stain- flat, irregular shaped lesion ranging from pale red to deep purple-red ■ Color deepens with exertion, emotional response, or exposure to extreme temperatures ■ Present at birth and typically does not fade ○ Spider angioma- flat, bright red dot with tiny radiating blood vessels ranging in size from a pinpoint to 2 cm; blanches with pressure ............continued