Techniques and Equipment for Physical Assessment
Exam 1 Assignment Guide and Vocabulary
Module 1: Vital Signs
Techniques and Equipment for Physical Assessment
● Provide examples/processes of the following infection control practices
○ Hand Hygiene: Follow World Health Organization (WHO) Guidelines
○ Personal Protective Equipment (PPE)
■ Gloves
● Protect healthcare workers from exposure to bloodborne pathogens
● Protect client from microorganisms on hands of healthcare workers
● Reduce potential of infection transmission from patient to patient via health care workers
■ Masks, Eye Protection, Face Shields
● Use when splashes/sprays of blood, body fluids are possible
■ Gowns
● Protect exposed skin or clothing from contamination
■ Managing Contaminated Equipment
● Never recap needle after client use
● Never remove needle from disposable syringe
● Place disposable syringes directly into “sharps container”
○ Latex Allergies
■ A reaction to protein in latex rubber
■ Risk Factors
● Health care professionals (8%-11%)
● General population (1%)
● Children with spina bifida
● Genitourinary surgery clients
■ Reactions
● Atopic dermatitis
○ No immune system involvement
● Type IV dermatitis
○ Delayed for 24-48 hours
● Type I dermatitis
○ Antigen-antibody reaction resulting in release of histamine
● Prevention
○ Use non-latex gloves
○ If latex are used use a powder-free, low-allergen glove
○ Wash hands immediately after removal of gloves
○ Always ask about latex allergies
○ Universal Precautions
■ Environmental Control
● Cleaning, disinfection of environmental surfaces used in examination per facility protocols
○ Tables
○ Counter surfaces
○ Exam lights
■ Patient Placement
● Place in private room when highly transmissible infection is present or if client is immunosuppressed
■ Respiratory Hygiene/Cough Etiquette
● Cover mouth/nose with tissue when coughing/sneezing and dispose in a no-touch trash receptacle
● Perform hand hygiene when hands are contaminated with respiratory secretions
● Wear surgical mask if patient is able when respiratory symptoms are present
● Maintain minimum of 3 feet from people in waiting area when possible
● Describe the following techniques of physical assessment. How are these altered for the pediatric patient?
○ Inspection
■ Visual exam of every body system
● Chest-rate, depth and effort of breathing
● Skin, lip and nail bed color
● Smell is part of inspection
● Ensure modesty with proper draping
○ Palpation
■ Requires nurse to move into personal space, so communicate with client about process (wear gloves)
● Touch for texture, size, shape, consistency, pulsation and locations
● Identify painful areas
■ Palmar surface (finger pads): more sensitive to palpation than fingertips
● Assesses position, texture, size, consistency, masses, fluid, crepitus
■ Ulnar surface: most sensitive to vibrations
■ Dorsal surface: most sensitive to temperature
■ Light Palpation (1st): press to depth of 1 cm
● Assesses skin, pulsations, tenderness
■ Deep Palpation (2nd): press to depth of 4cm
● Assesses size and contour of organ
○ Percussion (Direct and Indirect)
■ Direct:
● Used to evaluate sinus or costovertebral angle (CVA)
● Strike finger or hand directly against body
■ Indirect
● Requires both hands
● Indirect fist
○ Non-dominant hand on CVA with fingers together
○ Strike back of hand with fist of dominant hand
● Indirect finger
○ Place distal aspect of middle finger of non-dominant hand over organ being percussed
○ Strike the distal interphalangeal joint
■ 5 Percussion tones
● Tympany- abdomen
● Resonance- healthy lungs
● Hyperresonance- over-inflated lungs (emphysema)
● Dullness- over liver
● Flatness- over bones/muscle
○ Auscultation
■ Listening to sounds in body
● Sounds audible to ear- stridor, wheezing, abdominal gurgling
● Stethoscope- heart, lungs, blood vessels, intestines
■ Characteristics
● Intensity-sounds soft, medium or loud
● Pitch-frequency of sound waves per second (heart low, lungs high)
● Duration-(short, medium or long)
● Quality-(hallow, dull, crackle)
■ Tips for success
● Quiet environment
● Stethoscope directly on skin
● Warm head of stethoscope(prevents client muscle shivers)
● Firm pressure against chest hairs•Don’t bump stethoscope
● Clean between every client (infection control)
● Close eyes to minimize visual distraction
● Describe the importance of proper patient positioning
○ Sitting
■ Sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts.
○ Supine
■ most normally relaxed position. It provides easy access to pulse sites.
○ Dorsal Recumbent
■ This position is used for abdominal assessment because it promotes relaxation of abdominal muscles.
○ Lithotomy
■ This position provides maximal exposure of genitalia and facilitates insertion of vaginal speculum.
○ Sims
■ Flexion of hip and knee improves exposure of rectal area.
○ Prone
■ This position is used only to assess the extension of the hip joint.
○ Lateral Recumbent
■ This position assists in detecting murmurs.
○ Knee-Chest
■ This position provides maximal exposure of rectal area.
Chapter 6: Pain Assessment
● Please describe the following types of pain and provide an example of each
○ Acute
■ less than (<) 6 months
■ Tissue damage
■ Increases BP, HR, RR
○ Nociceptive
■ Somatic structures (bone, joint, muscle, organs)
○ Neuropathic
■ Central or peripheral nervous system
○ Chronic
■ more than (>) 6 months
■ Irritability, depression, insomnia
○ Referred
■ Felt in area away from tissue injury/disease
■ Abdominal organs do not have pan receptors
■ Stimulates nerves from unaffected areas
■ Example: gallbladder causes pain to right shoulder
■ Example: MI causes pain left shoulder, arm or jaw (men)
○ Phantom
■ Felt after amputation of extremity
■ Nerve pathway from amputation is stimulated and sends impulse to cerebral cortex
● A-delta fibers are associated with what type of pain
○ associated with a sharp, pricking, acute, well-localized pain of short duration
● C fibers are associated with what type of pain
○ associated with a dull, aching, throbbing, or burning sensation that is diffuse, has a slow onset, and a relatively long duration
● Describe the difference between the pain threshold and pain tolerance
○ pain threshold: the point at which a stimulus is perceived as pain; does not vary significantly over time
○ pain tolerance: the duration or intensity of pain that a person endures or tolerates before responding outwardly; decreases with repeated exposure to pain, fatigue, anger, boredom, apprehension, and sleep deprivation
● Provide an example using OLDCARTS for pain assessment
○ OLDCARTS
■ Onset
● When pain began and the activity performed at time pain began
■ Location
● Can client point to area of pain?
○ Yes- localized (visceral)
○ No- somatic
■ Duration
● Intermittent- may be from ischemia
● Constant- may be tissue damage
■ Characteristics
● Describe what pain feels like
○ McGill Pain Questionnaire
■ Aggravating Factors/Alleviating
● What makes it worse?
● What makes it better?
■ Related Symptoms
● Palpitations, shortness of breath, nausea/vomiting?
■ Treatment
● What have they tried to treat pain?
■ Severity
● How bad is pain?
● Use pain scale
● Describe the pain assessment scales and associated usage
○ Conscious/Verbal Client
■ Numeric Rating Scale (NRS)
● 0-10
● 0-no pain
● 10-worst pain possible
○ Non-verbal Child
■ FLACC Pain Scale
● Facial expression (0-2)
● Leg movement (0-2)
● Activity (0-2)
● Cry (0-2)
● Consolability (0-2)
○ Non-verbal Adult
■ Adult Nonverbal Pain Scale (NVPS)
● Facial expressions
● Activity (movement)
● Guarding
● Physiologic I (vital signs)
● Physiologic II (skin, pupillary response, perspiration
● (each category is 0-2 with total possible range from 0-10)
● Additional Vocabulary:
○ Gate Control Theory
○ Wong-Baker Faces Scale
Module 2: General Inspection and Health History
Introduction to Health Assessment
● The Nursing Process
○ Step 1: Assessment
■ Comprehensive data pertinent to health care situation
● Includes subjective and objective data
○ Client statements (subjective data)
○ Physical examination (objective data)
○ Step 2: Diagnosis
■ Analyze assessment findings
■ Identify abnormal findings
■ Label problem, cause and evidence
■ Example: Pain related to (R/T) knee abrasion as evidenced by (AEB) client reports pain 8/10 on numeric pain scale
○ Step 3: Outcome Identification
■ Set a goal for the client
■ Relevant, achievable, realistic and within nursing scope of practice:
■ Example: Client will report a decrease in pain score to 3/10 on the numeric pain scale by the end of the 12 hour clinical shift
○ Step 4: Planning
■ Develop a plan to meet the goal
● Medication
● Nonpharmacologic methods of pain management
■ Assess what client does to treat pain and the available pain medications, if none available contact physician for order
■ Use distraction until medication is available
○ Step 5: Implementation
■ Coordinate care
● Engage healthcare team
■ Health teaching/promotion
● Educate client on non-pharmacological methods of pain medication
■ Consultation
● Is specialty nurse/doctor needed?
■ Prescriptive authority/treatment
● Advanced practice nurses have prescriptive authority
○ Step 6: Evaluation
■ Did the intervention (pain medication/distraction) meet the goal? (Is pain level now at 3/10 or lower?)
○ Documentation
■ Legal record of the visit
■ Complete, accurate, and descriptive data of assessment and plan of care
● Electronic Health Record (EHR)
● Paper records
● If it is not documented, it didn't happen
● Types of Health Assessment
○ Depends on...
■ Context of care
● setting/environment, socioeconomic/psychological circumstances
■ Patient need
● comprehensive, problem-based, follow up, shift, screening
■ Nurse expertise
○ Comprehensive: detailed history and physical at onset of care or admission to hospital/long term care
○ Problem-based: limited to specific problem
■ (walk-in clinic, emergency room, specialty clinic)
○ Episodic/follow-up: previously identified problem
■ (chronic illness, acute illness follow up)
○ Screening assessment: short examination to focus on detecting disease
■ (glucose screening, colorectal screening)
○ Shift Assessment: hospitalized client’s are assessed for changes in condition
■ Compare/contrast data received in shift report versus assessment findings during shift
■ (v/s, orientation, heart, lungs, bowel, movement, perfusion, skin integrity, lines/drains lab values, etc.)
■ Analyze data, interventions, document, and report changes to team
● Obtaining a Health History
○ Collect subjective patient data to allow for development of plan to promote health
○ Components of Health History
■ Biographic data
■ Reason for seeking health care
● No more than 1-2 sentences
■ History of present illness
■ Present health status
■ Past health history
■ Family history
● 3 generations (see genogram)
■ Personal and psychosocial history
■ Review of Systems (subjective data)
○ The Interview
■ Health history is obtained
■ Nurse facilitates discussion
● May include client questionnaire
● (should not replace interview)
■ Introduction Phase
● Introduce to client
● Describe purpose of interview
● Describe process
■ Discussion Phase
● Facilitate patient centered discussion
● Use communication techniques to collect data
■ Summary Phase
● Summarize data with client
● Allow client to clarify data
● Communicates understanding of client issues
○ Physical Setting
■ Should be private
■ Physical comfort
● Temperature
● Modesty protected
● Sit at appropriate distance
○ Enhance Data Collection
■ Active Listening
● Concentrated on client statements
● Note facial expressions and body language
● Don’t predict what client will say
■ Facilitation
● Use phrases to encourage client to continue
● “go on” “uh-huh” “then”
■ Clarification
● Obtain more information about vague or conflicting statements
■ Restatement
● Repeat client statement to confirm interpretation
■ Reflection
● Clarification by restating phrase used by client in form of question
■ Confrontation
● Used when inconsistencies are noted between the client report and observations or other data
● Use caution to avoid accusatory tone
○ Utilize confusion tone instead
■ Interpretation
● Use to share conclusions based on information received
● Example: “you stated you were on steroids when the glucose level was drawn, I am guessing this might have increased your levels”
■ Summary
● Condenses and orders data obtained to develop sequence of events
● Useful for clients who do not provide sequential data
○ Diminish Data Collection
■ Medical Terminology
● May confuse client and lead to miscommunication or inaccurate data collection
■ Expressing value judgments
● Do not belong in client interview
● May cause client to feel futility or defensive and lead to inaccurate data
■ Interrupting the client
● Allow client to finish sentences/thoughts
■ Being Authoritarian or Paternalistic
● Risks alienating client
● Clients have right to follow or ignore advice offered by nurse
■ Using “Why” questions
● Places client on defensive
○ Managing Awkward Moments
■ Answering Personal Questions
● Clients may be curious about nurse
● Brief direct response generally works
■ Silence
● Client’s may need moment to gather thoughts
■ Displays of Emotion
● Crying
○ Is a natural emotion (allow time)
○ Asking client to stop crying is not therapeutic
● Anger
○ Deal with directly by identifying source
○ Acknowledge feelings and apologize if necessary
○ Challenges to Interview
■ Talkative Client
● Use open closed ended question (yes/no)
■ Others in Room
● Don’t assume relationships
● Don’t assume that relationships exist/ok to include in conversation
● Pediatric clients/visitors- find appropriate activity to allow for interview
■ Language barrier
● Obtain interpreter
○ State and Federal laws mandate
○ Allow extra time for interview
● Do not utilize family member
Chapter 4: General Inspection and Measurement of Vital Signs
● Describe expected and abnormal findings during a general inspection of:
○ Physical appearance and hygiene
■ Do you notice tremors, facial drooping?
■ Does client appear stated age? (older or younger)
■ Obvious skin lesions
■ Are they clean/well groomed?
■ Any odors detected? (good/bad)
■ Appear disheveled? (wrinkled clothes/unbrushed hair)
○ Body structure and position
■ Stature-(well nourished, obese, cachectic)
■ Body symmetry-(right side matches left side)
■ Posture- (upright, slumped, tripod, fetal position)
○ Body movement
■ Walk with ease? (smooth, balanced, symmetrical movement of extremities, walker, tremor, tic)
○ Emotional and mental status/behavior
■ Eye contact, alert, converse appropriate, body language, clothing appropriate for weather, behavior appropriate for situation/setting
● Describe expected ranges and variances for the following
○ Temperature- (oral, temporal, tympanic axillary and rectal)
■ Oral Temperature
● Smoking, food intake impact accuracy
○ Delay 10 minutes
○ Cover probe with disposable sheath
○ Place in sublingual pocket- measures carotid artery temperature•Instruct client to keep mouth closed
○ Takes approx. 15-30 seconds
○ Safe for adults, and school age children
○ Pacifier thermometer for small children
■ Temporal Artery
● Measures temporal artery using infrared technology
● Skin surface of forehead is detected while scanning
● Place disposable cover on probe
● Place center of forehead, depress scan button, maintain contact slide towards hairline and behind ear, release button
● High level of accuracy
■ Tympanic Membrane
● Infrared technology measures tympanic membrane
● Tug ear upward on helix for adults to straighten ear canal and down on children to ensure accuracy
● Probe must come into contact with all side of ear canal, but not touch the tympanic membrane
● Takes about 2-3 seconds
■ Axillary Temperature
● Common site in infants/children
● Not close to major blood vessels
● Poorly reflects core temperature
● Place in middle of axilla with arm held against body
● Generally 1 F below oral temperature
■ Rectal Temperature
● Most accurate
● Invasive
● Increased risk of infection
● Place in Sims position (table 3-2)
● Apply water soluble lubricant
● Insert 1-1.5 inches hold until signal
● Readings are 1 F higher than oral
○ Heart rate and rhythm-(regular, regular irregular, irregular irregularity)
■ Expected Averages:
● Newborn: 120-160 bpm
● Toddler: 90-140 bpm
● School age: 75-100 bpm
● Adolescent: 60-90 bpm
● Adult: 60-100 bpm
■ Technique-finger pads to palpate
● Rate- pulsations felt in 1 minute
● Rhythm- regularity of pulsations (time between beats)
■ Regular rhythm (evenly spaced)
● Count pulsations in 15 sec. X 4
● Count pulsations in 30 sec. X2
■ Irregular rhythm (beat varies)
● Regular irregularity (repeating pattern)
● Irregular irregularity (no pattern)•Count 1 full minute
■ Sites: Radial, Brachial, Carotid
○ Respiratory rate
■ Expected Averages
● Newborn: 30-60 breaths/min
● Toddler: 24-40 breaths/min
● School Age: 18-30 breaths/min
● Adolescent: 12-16 breaths/min
● Adult: 12-20 breaths/min
■ Technique:
● Count number of complete ventilatory cycles in 1 minute
○ Women- thoracic breathers
○ Men-abdominal breathers
● Count when client is unaware
○ Pretend to count pulse
● Assess
○ Rate- number of complete cycles
○ Rhythm-regular or irregular
○ Depth-deep, normal, or shallow
● Expected
○ Even, quiet, effortless
● Factors that change RR
○ Fever, anxiety, exercise, increased altitude(8000 feet)
○ Blood Pressure
● Force of blood against the arterial walls
● Reflects cardiac output (volume of blood/minute) and peripheral resistance (force that opposes flow of blood)
● Systolic Blood Pressure (SBP)
○ Maximum pressure exerted on arteries when ventricles contract/eject
● Diastolic Blood Pressure (DBP)
○ Minimum pressure exerted on vessels when ventricles relax/fill
○ Documented as SBP/DBP mm Hg
● Pulse Pressure: SBP-DBP=30-40 mmHg
● Orthostatic B/P: 20-30 mmHg drop with position changes
■ Average Ranges: (mm Hg)
● Newborn: SBP-60-90/DBP 20-60
● Toddler: SBP-80-112/DBP 50-80
● School Age: SBP 84-120/DBP 54-80
● Adolescent: SBP 94-139/DBP 62-88
● Adult: SBP 110-139/DBP 60-79
■ Method
● Direct Measurement
○ small catheter is placed into artery (critical care)
● Indirect Measurement
○ auscultation using sphygmomanometer and stethoscope
○ Oscillometric blood pressure- automated blood pressure device
● Technique
○ Auscultation of Korotkoff
○ Blood flows freely until inflated cuff occludes the artery (silence)
○ Cuff is slowly released until sounds of blood pulsate through artery again (1st Korotkoff sound)
○ 1st Korotkoff sound is SBP
○ 5th Korotkoff is the cessation of sound and indicates artery is open (DBP)
● Auscultation Technique
○ Place client in sitting or supine position with upper arm flexed at level of heart with palm up
○ Palpate brachial pulse
○ Select size of cuff
■ Adult
● Cuff width should be 40% circumference
● Bladder should cover 80% circumference
■ Child/Infant
● Width should cover 2/3 upper arm
■ Place snugly 1 inch (2.5cm) above antecubital space
○ Do not place on side of IV, dialysis fistula, or mastectomy
○ Position sphygmomanometer at eye level approx. 3 feet and close valve clockwise
○ Palpate brachial/radial pulse and inflate cuff rapidly
■ Note when pulse is lost ( palpated SBP) and inflate 20-30 mmHg higher
○ Slowly release cuff (counterclockwise) and note when pulse returns (palpated DBP) and deflate completely
○ Wait 30 seconds
○ Place stethoscope at brachial artery and inflate to palpated + 20-30 mmHg
○ Release pressure 2-3 mm Hg per second
○ Note korotkoff sounds, deflate, document
● Automated Blood Pressure
○ Monitor senses and converts vibrations into electrical impulses and translates into digital readout
■ Concerns about accuracy
■ Sensor must be placed over brachial artery
■ When in doubt check using auscultation
● Thigh Pressure
○ Place in prone (face down) position or supine (face up)
○ Center cuff over popliteal artery
○ Generally SBP 10-40 mm Hg higher in leg than arm
■ Assessment Sites
● Upper arm-(preferred site)
● Thigh
● Calf
● Ankle- (preferred alternate site)
● Forearm-(not very reliable)
■ False high/lows for blood pressure
● High
● Client legs crossed
● Arm below level of heart
● Cuff too narrow
● Cuff too loose or uneven
● Deflate too slow (slower than 2-3 mm Hg/second)
● Reflating before completely deflated
● Failure to wait 1-2 minutes before repeating
■ Physiologic factors that affect blood pressure
● Age- gradual rise
● Gender- females lower after puberty until menopause then higher than men
● Pregnancy-DBP drops during 1st/2nd trimesters returns to normal 3d trimester
● Race- African Americans experience elevations 2X more often than Caucasians
● Diurnal variations-lower in morning peaks in afternoon/early evening
● Emotions- anxiety, anger, stress can increase•Pain- acute pain causes increase
● Personal habits-caffeine, smoking 30 minutes before measure increases
● Weight-obesity makes higher
○ Oxygen saturation
■ Pulse oximeter-estimates oxygen saturation of hemoglobin in blood
■ Clipped/taped to finger, earlobe, nose, toe
■ Saturations lower 90% are abnormal
○ Pain
■ 5th vital sign
○ Height
■ Measured on platform scale without shoes
■ Vertical measurement in inches/centimeters
■ Adult height achieved at 18-20
○ Weight
■ Important nutritional assessment
● Unintentional changes can indicate significant findings
■ Calculate medication dosages
■ Fluid retention
● 1000 ml fluid equals 1 kg (2.2 lbs.)
● Additional Vocabulary:
○ afebrile: not feverish
○ bradycardia: abnormally slow heart action
○ bradypnea: abnormally slow breathing
○ core temperature: the temperature of the internal environment of the body
○ cyanosis: a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood
○ diastolic blood pressure: measures the pressure in your blood vessels when your heart rests between beats
○ diurnal variations: fluctuations that occur during each day
○ febrile: feverish
○ hyperthermia: the condition of having a body temperature greatly above normal
○ hypothermia: the condition of having a body temperature greatly below normal
○ hypotension: abnormally low blood pressure
○ hypertension: abnormally high blood pressure
○ Korotkoff sounds: blood flow sounds that appear and disappear with inflation while taking blood pressure with a sphygmomanometer over the brachial artery in the antecubital fossa
○ manual blood pressure measurement: non-automated way to estimate blood pressure
○ orthostatic hypotension: a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position
○ oscillometric blood pressure measurement: automated cuff yields valid estimates of mean pressure but questionable estimates of systolic and diastolic pressures
○ oxygen saturation: commonly referred to as {"sats"}; measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen
○ pulse oximeter: device that measures the oxygen saturation of your blood
○ pulse pressure: the difference between systolic blood pressure and diastolic blood pressure
○ rate: the speed or frequency with which an event or circumstance occurs per unit of time, population, or other standard of comparison
○ rhythm: the regularity or consistency with which an event or circumstance occurs per unit of time, population, or other standard of comparison
○ stethoscope: a medical instrument for listening to the action of someone's heart or breathing
○ sphygmomanometer: an instrument for measuring blood pressure
○ systolic blood pressure: specifically the maximum arterial pressure during contraction of the left ventricle of the heart
○ tachycardia: an abnormally rapid heart rate
○ tachypnea: abnormally rapid breathing
Module 3: Skin, Hair, and Nails
Chapter 9: Skin, Hair, and Nails
● List the recommendations to reduce skin Cancer
○ cover with tightly woven clothing
○ wide brim hat
○ SPF 15 or higher (even when cloudy)
○ sunglasses to protect skin around eyes
○ avoid sunbathing and indoor tanning
○ screening using the mnemonic ABCDEF
● Describe the ABCDEF mnemonic of Melanoma
○ Asymmetry (not even)
○ Border (poorly defined or irregular)
○ Color (uneven, variegated)
○ Diameter (usually >6mm)
○ Evolving/Elevations (changes from flat to raised)
○ Feeling (itching, tingling or stinging)
● Define hypopigmentation and provide an example
○ loss of skin color/melanin depletion; albinism
● Define hyperpigmentation and provide an example
○ excess melanin/darkening of skin; melasma
● Describe the following expected variations of skin inspection
○ Pigmented nevi (mole):
■ 10-40 usually above waist or sun exposed areas
■ typically <5mm
■ uniform color
■ can be papule (raised) or macule (flat); both are <1cm in diameter
■ round or oval
■ clearly defined border
○ Freckles:
■ small, macule (flat), <1cm in diameter
■ hyperpigmented
■ appear anywhere on body (especially sun-exposed area)
○ Patch:
■ some can be normal, expected (birthmarks)
■ some can be abnormal, unexpected (carcinomas)
○ Striae (stretch marks):
■ silver/pink
■ generally secondary to weight gain or pregnancy
● Describe the following abnormal variations of skin inspection
○ Melanoma:
■ unexpected to the pigmented nevi
■ consisted to ABCDEF mnemonic
○ Vitiligo:
■ abnormal finding
■ acquired condition
■ development of unpigmented patch(es)
■ more common in dark-skinned individuals
■ thought to be an autoimmune disorder
○ Moles:
■ when in large numbers or dysplastic nevus, moles can be a skin cancer risk
● Explain the clinical significance of cool skin
○ associated with shock or hypothermia
○ localization may be indication of poor peripheral perfusion
● Explain the clinical significance of hot skin
○ hyperthermia
■ fever, hyperthyroidism, exercise
○ localization may reflect inflammation, infection, traumatic, injury, or thermal injury (sunburn)
● Describe the correct assessment method for assessing skin temperature
○ palpate with dorsal aspect of hands
■ should be warm
■ should be consistent for entire body
■ hands/feet may be cooler
● Explain the clinical significance of diaphoresis; what disease conditions can be associated with diaphoresis
○ excess moisture abnormal in absence of strenuous activity
○ hyperthermia, extreme anxiety, pain, or shock (cool and diaphoretic), hyperthyroidism
● Describe the process of assessing skin turgor; what locations are most appropriate? List normal and abnormal findings associated with skin turgor
○ Technique:
■ pick up and slightly pinch skin or forearm or under clavicle
○ Normal:
■ should be elastic (move easily when lifted)
■ should return immediately when released
○ Abnormal:
■ tenting-dehydration or excess weight loss
■ reduced mobility- edema, excess scarring, or scleroderma (connective tissue disorder)
● What is the cause of “tenting”
○ dehydration or excess weight loss
● What chronic disease can result in skin thickening?
○ diabetes can cause abnormal collagen resulting from hyperglycemia
● Excessively thin skin or shiny skin is the result of what?
○ seen in hyperthyroidism, arterial insufficiency and aging
● Correctly document shape, patterns and lesions including the following
○ Round/oval: solid appearance, no central clearing
○ Annular: round with central clearing (tinea corporis)
○ Iris: pink macule with purple concentric ring (erythema multiforme)
○ Gyrate: snake-like appearance
○ Singular/discrete: single lesion, demarcated lesions that are separate (insect bite)
○ Grouped/clustered: lesions that bunch together in little groups (herpes simplex)
○ Polycyclic: annular lesions that come in contact with each other as they spread
○ Confluent:
○ Linear
○ Zosteriform
○ Generalized
○ Macule: flat, circumscribed area; change in the color of the skin; <1 cm diameter
○ Papule: elevated, firm, circumscribed area; <1 cm in diameter
○ Patch: flat, nonpalpable, irregular-shaped macule; >1 cm in diameter
○ Plaque: elevated, firm, and rough lesion with flat top surface >1 cm in diameter
○ Wheal: elevated irregular-shaped area of cutaneous edema; solid, transient; variable diameter
○ Nodule: elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 to 2 cm in diameter
○ Tumor: elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter
○ Vesicle: elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter
○ Bulla: Vesicle greater than 1 cm in diameter
○ Pustule: Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid
○ Cyst: Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material
○ Scale: Heaped-up keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size
○ Lichenification: Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surface of extremity
○ Keloid: Irregular-shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound
○ Scar: Thin-to-thick fibrous tissue that replaces normal skin following injury or laceration to the dermis
○ Excoriation: Loss of the epidermis; linear hollowed-out crusted area
○ Fissure: Linear crack or break from the epidermis to the dermis; may be moist or dry
○ Crust: Dried drainage or blood; slightly elevated; variable size; colors variable—red, black, tan, or mixed
○ Erosion: Loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla
○ Ulcer: Loss of epidermis and dermis; concave; varies in size
○ Atrophy:
○ Petechiae:Tiny, flat, reddish-purple, nonblanchable spots in the skin less than 0.5 cm in diameter; appear as tiny red spots pinpoint to pinhead in size; Cause: tiny hemorrhages within the dermal or submucosa—caused by intravascular defects and infection
○ Purpura: Flat, reddish-purple, nonblanchable discoloration in the skin greater than 0.5 cm in diameter; Cause: infection or bleeding disorders resulting in hemorrhage of blood into the skin
○ Ecchymosis: Reddish-purple, nonblanchable spot of variable size Cause: trauma to the blood vessel resulting in bleeding under the tissue
○ Angioma: Benign tumor consisting of a mass of small blood vessels; can vary in size from very small to large
○ Capillary hemangioma (Nevus Flammeus): Type of angioma that involves the capillaries within the skin producing an irregular macular patch that can vary from light red to dark red to purple in color
○ Telangiectasia: Permanent dilation of preexisting small blood vessels (capillaries, arterioles, or venules) resulting in superficial, fine, irregular red lines within the skin
○ Vascular spider: Type of telangiectasia characterized by a small central red area with radiating spider like legs; this lesion blanches with pressure may occur in absence of disease, with pregnancy, in liver disease, or with vitamin B deficiency
○ Venous star: Type of telangiectasia characterized by a nonpalpable bluish, star-shaped lesion that may be linear or irregularly shaped Cause: increased pressure in the superficial veins
● Describe possible causes of dull, coarse, brittle hair
○ nutritional deficiencies, hypothyroidism, exposure to chemicals
● How do thyroid abnormalities impact changes in hair distribution?
○ causes hair to be dull, coarse, and brittle
● What is alopecia?
○ hair loss; can be caused by autoimmune disorders, anemic conditions, nutritional deficiencies, radiation or antineoplastic treatments
● What is the significance of hair loss on the lower legs?
○ loss of perfusion
● What is hirsutism?
○ This is a condition associated with an increase in the growth of facial, body, or pubic hair in women. Hirsutism has familial tendency and can be associated with endocrine disorders; polycystic ovarian disease; menopause; and side effects of medications, especially corticosteroid or androgenic steroid therapy. 24 Clinical Findings: An increase of body or facial hair is seen; the amount of hair varies. This condition is more pronounced among individuals with darkly pigmented hair. Increased hair growth may or may not be associated with other signs of virilization when secondary male sexual characteristics are acquired by females
● What is koilonychia and what are possible causes?
○ Koilonychia (spoon nail) presents as a thin, depressed nail with the lateral edges turned upward (Fig. 9-6). This is associated with anemia or may be congenital. 15
● What is leukonychia and what is a possible cause?
○ Leukonychia appears as white spots on the nail plate (Fig. 9-8). This is usually caused by minor trauma or manipulation of the cuticle.
● What is clubbing? What does it represent?
○ Clubbing is present when the angle of the nail base exceeds 180 degrees (Fig. 9-9). It is caused by proliferation of the connective tissue, resulting in an enlargement of the distal fingers. Clubbing is most commonly associated with chronic respiratory or cardiovascular disease.
● What are Beau’s lines?
○ Beau’s lines manifest as a groove or transverse depression running across the nail. They result from a stressor such as trauma that temporarily impairs nail formation. The groove first appears at the base of the nail by the cuticle and moves forward as the nail grows out.
● What would indicate a positive wood’s lamp assessment?
○ Use a Wood’s lamp to identify fluorescing lesions, indicating fungal infection. Darken the room and shine the light on the area to be examined. If there is no fungal infection, the light tone on the skin appears soft violet
○ A yellow-green or blue-green fluorescence indicates the presence of fungal infection.
● Distinguish between Stage I-IV pressure ulcer
○ Stage I: intact non-blanchable redness
○ Stage II: partial-thickness, shallow open ulcer with pink wound bed
■ no slough
■ may also appear as bulla (blister)
○ Stage III: full thickness skin loss
■ visible subcutaneous fat
■ no bone, tendon, or muscles exposed
■ slough may be present
■ wound may have undermining and tunneling
■ depth depends on location r/t varied anatomic skin depths
○ Stave IV: full thickness skin loss
■ bone, tendon, or muscle are exposed
■ slough or eschar may be present in wound bed
■ undermining and tunneling often present
■ depth depends on location
● What is an unstageable ulcer?
○ can’t see how deep it goes; do not remove slough or eschar
● What is a deep tissue injury? -all the way down to the bone, or a giant bruise
● Birthmarks
○ CONGENITAL DERMAL MELANOCYTOSIS AKA MONGOLIAN SPOT
■ IRREGULAR PATCH ON SACRUM AND BUTTOCKS
■ MOST PREVALENT IN AFRICAN DARKER SKINNED CHILDREN
■ USUALLY DISAPPEARS BY AGE 1-2 YEARS
○ CAFÉ AU-LAIT SPOT
■ LARGE ROUND/OVAL PATCH
■ LIGHT BROWN IN COLOR
■ OCCASIONALLY ASSOCIATED WITH NEUROFIBROMATOSIS (TUMOR GROWTH IN NERVOUS SYSTEM)
○ TELANGIECTASIA/FLAT CAPILLARY HEMANGIOMA AKA STORK-BITE
■ COMMON VASCULAR BIRTHMARK
■ SMALL, RED OR PINK SPOT SEEN ON BACK OF NECK OR EYELIDS
■ USUALLY DISAPPEARS BY 5 YEARS OF AGE
○ NEVUS FLAMMEUS •AKA PORT-WINE STAIN
■ LARGE, MACULE
■ BLUISH/PURPLE CAPILLARY AREAS
■ USUALLY ON FACE ALONG 5TH CRANIAL NERVE
■ DOES NOT DISAPPEAR
○ STRAWBERRY HEMANGIOMA
■ SLIGHTLY RAISED
■ RED WITH SHARP DEMARCATION LINE
■ MAY BE 2-3 CM DIAMETER
■ USUALLY DISAPPEAR BY 5 YEARS OF AGE
○ CAVERNOUS HEMANGIOMA
■ REDDISH-BLUE MASS OF BLOOD VESSELS
■ MAY CONTINUE TO GROW UNTIL 10-15 MONTHS OF AGE
■ SHOULD BE ASSESSED FREQUENTLY
● Describe the following common conditions
○ Clavus: A corn is a lesion that develops secondary to chronic pressure from a shoe over a bony prominence.
○ Atopic dermatitis: •ASSOCIATED WITH HAY FEVER AND ASTHMA•MAY BE FAMILIAL •MORE COMMON IN INFANCY AND CHILDHOOD
○ Contact dermatitis: REACTION TO EXPOSURE TO IRRITANTS OR ALLERGENS (METALS, PLANTS, CHEMICALS, OR DETERGENTS)
○ Seborrheic dermatitis: CHRONIC INFLAMMATION WITH REMISSIONS AND EXACERBATIONS •UNKNOWN CAUSES
○ Stasis dermatitis: •ASSOCIATED WITH VENOUS STASIS, CHRONIC EDEMA AND POOR PERIPHERAL CIRCULATION •MOST COMMON IN OLDER ADULTS
○ Psoriasis: •CHRONIC SKIN DISORDER THAT USUALLY DEVELOPS BY AGE 20•INFLAMMATORY CYTOKINES FROM ACTIVATED HELPER T-CELLS CAUSE LESIONS •CAN RANGE FROM MILD TO SEVERE •NURSING DX: IMPAIRED SKIN INTEGRITY R/T INFLAMMATORY CYTOKINES AEB WELL-CIRCUMSCRIBED, RAISED PLAQUES WITH SILVERY SCALES ON THE ELBOWS, KNEES, BUTTOCKS, LOWER BACK AND SCALP WITH SMALL BLEEDING POINTS •PATIENT ALSO COMPLAINS OF PRURITUS, BURNING AND BLEEDING OF LESIONS AND PITTING OF FINGERNAILS
○ Pityriasis rosea: COMMON ACUTE SELF-LIMITING INFLAMMATORY DISEASE USUALLY FOUND IN YOUNG ADULTS DURING WINTER MONTHS •MAY BE ASSOCIATED WITH A VIRUS •NURSING DX: IMPAIRED SKIN INTEGRITY R/T INFLAMMATION AEB HERALD PATCH EVOLVING TO MULTIPLE MACULAR AND VESICULAR LESIONS ON TRUNK AND EXTREMITIES
○ Warts (verruca): CAUSED BY HUMAN PAPILLOMAVIRUS (HPV)•TRANSMITTED BY CONTACT •OVER 60 DIFFERENT TYPES OF HPV •MANY LOCATIONS AND MANY SIZES•NURSING DX: IMPAIRED SKIN INTEGRITY R/T VIRAL INFECTION AEB IRREGULAR SHAPED LESION OF LIGHT GRAY, YELLOW, OR BROWNISH BLACK ON HANDS, FINGERS, ELBOWS AND KNEES •PLANTAR WARTS ARE FOUND OF SOLE OF FOOT AND TENDER TO PRESSURE
○ Herpes simplex: EIGHT DIFFERENT DEOXYRIBONUCLEIC ACID (DNA) VIRUSES •CHRONIC, LAYS DORMANT BETWEEN OUTBREAKS •TRIGGERED BY SUN EXPOSURE, STRESS AND FEVER •NURSING DX: IMPAIRED SKIN INTEGRITY R/T DNA VIRUS AEB GROUPED VESICLES PUSTULES AND CRUSTING ON A ERYTHEMATOUS BASE ON UPPER LIP (COLD SORE HSV 1) OR GENITALIA (HSV 2) •TYPICALLY LAST 2 WEEKS •PATIENTS EXPERIENCE PAIN, TINGLING PRIOR TO OUTBREAKS
○ Herpes Varicella (Chickenpox): HIGHLY COMMUNICABLE VIRAL INFECTION SPREAD BY DROPLETS •IMPAIRED SKIN INTEGRITY R/T VIRAL INFECTION AEB INITIAL LESION ON THE TRUNK THAT SPREADS TO EXTREMITIES AND FACE BEGINNING WITH MACULES, PAPULES, VESICLES AND CRUSTING •INFECTIVE FROM FEW DAYS BEFORE LESIONS UNTIL FINAL LESIONS HAVE CRUSTED (USUALLY 6 DAYS AFTER FIRST LESION ERUPTED)
○ Herpes Zoster (Shingles): ACUTE INFLAMMATION BY REACTIVATION OF DORMANT HERPES VARICELLA VIRUS •NURSING DX: IMPAIRED SKIN INTEGRITY R/T DORMANT VIRUS AEB: LINEARLY GROUPED VESICLES, PUSTULES AND CRUSTS ALONG UNILATERAL NERVE LINE (DERMATOME) ON FACE, TRUNK ETC.•VERY PAINFUL
○ Tinea infections
■ TINEA CORPORIS (RINGWORM)• CIRCULAR LESIONS WITH CLEAR CENTER ON GENERALIZED SKIN AREAS EXCEPT SCALP, FACE, HANDS, FEET AND GROIN
■ TINEA CRURIS (JOCK ITCH)•HYPER PIGMENTED SCALING VESICULAR PATCHES APPEARS IN GENITALS AND UPPER THIGHS
■ TINEA CAPITIS- • SCALING AND PRURITUS WITH BALDING AREAS AND HAIR BREAKAGE ON SCALP
■ TINEA PEDIS (ATHLETE’S FOOT)• SMALL WEEPING VESICLES AND PAINFUL MACERATED AREAS BETWEEN TOES AND SOLE OF FOOT APPEARS ON FOOT
○ Candidiasis: •CANDIDA ALBICANS NORMALLY FOUND ON SKIN, MUCOUS MEMBRANES, GI TRACT AND VAGINA •GROWS IN WARM, MOIST AREAS OR IN TISSUE MACERATION, DM, AIDS PATIENTS, AND SYSTEMIC ANTIBIOTIC ADMINISTRATION •IMPAIRED SKIN INTEGRITY R/T FUNGAL INFECTION AEB LARGE PATCH OF AND LOOSE SCALES RED RASH WITH SHARP BORDERS ON SKIN , GENITALIA, GLUTEAL FOLDS, INGUINAL AREA
○ Cellulitis: •ACUTE STREPTOCOCCAL OR STAPHYLOCOCCAL INFECTION OF SKIN •OCCURS AT ANY AGE/AREA OF BODY •RED WARM, TENDER, AND APPEARS TO BE INDURATED •MAY BE REGIONAL LYMPHANGITIC STREAKS AND LYMPHADENOPATHY
○ Impetigo: HIGHLY CONTAGIOUS BACTERIAL INFECTION CAUSED BY GROUP A STREPTOCOCCUS AND TRANSMITTED BY CONTACT •OCCURS IN CROWDED AREAS WITH POOR SANITATION •USUALLY MOST PREVALENT IN CHILDREN IN MID-LATE SUMMER•AEB: MACULES, VESICLES OR BULLAE WITH HONEY COLORED CRUST ON FACE, NOSE AND MOUTH •OTHER AREAS OF SKIN CAN BE INVOLVED
○ Folliculitis: •CHRONIC DEEP HAIR FOLLICLES ARE INFECTED (BEARDED AREA) •IMPAIRED SKIN INTEGRITY R/T INFLAMMATION OF HAIR FOLLICLES AEB ERYTHEMA WITH A PUSTULE SURROUNDING HAIR FOLLICLE ON SCALP AND EXTREMITIES
○ Furuncle/abscess: LOCALIZED BACTERIAL LESION CAUSED BY STAPHYLOCOCCAL PATHOGEN •OFTEN DEVELOP FROM FOLLICULITIS •IMPAIRED SKIN INTEGRITY R/T STAPHYLOCOCCAL INFECTION AEB RED EDEMATOUS NODULE, PUSTULE AND SANGUINEOUS PURULENT EXUDATE FROM CENTER (CORE)
○ Scabies: HIGHLY CONTAGIOUS INFESTATION OF SARCOPTES SCABIEI MITE•FEMALE MITE BURROWS INTO SUPERFICIAL LAYER OF SKIN AND LAYS EGGS •TRANSMISSION WITH DIRECT SKIN TO SKIN CONTACT •IMPAIRED SKIN INFECTION R/T SARCOPTES SCABIEI AEB SMALL PAPULES, VESICLES AND BURROWS IN HANDS, WRISTS, AXILLAE, GENITALIA AND INNER ASPECTS OF THIGH •HALLMARK SIGNS SEVERE PRURITUS RELATED TO SENSITIVITY OF MITE AND ITS FECES •BURROWS LOOK LIKE MADE BY END OF A PENCIL
○ Lyme disease: TICK BITE INFECTED WITH BORRELIA BURGDORFERI •MOST COMMON VECTOR BORNE ILLNESS IN U.S. (MOST COMMON IN NORTHEAST STATES)•AEB: EXPANDING ERYTHEMA RASH WITH CENTRAL CLEARING AT SIDE OF TICK BITE EXCEEDING 5 CM AND PRESENT FOR SEVERAL WEEKS.•MOST INDIVIDUALS ALSO EXPERIENCE FLU LIKE SYMPTOMS (FEVER, HEAD/MUSCLE ACHES)
○ Spider bites
■ BLACK WIDOW•FOUND THROUGHOUT U.S.•MINIMAL SYMPTOMS AT TIME OF BITE •ERYTHEMA WITH TWO RED PUNCTA •WITHIN HOURS SEVERE ABDOMINAL PAIN/ FEVER
■ BROWN RECLUSE•FOUND IN CENTRAL AND SOUTH CENTRAL U.S. •MINIMAL SYMPTOMS AT TIME OF BITE•INITIAL LESION WITH ERYTHEMA AND EDEMA EVOLVING INTO NECROTIC ULCER WITH ERYTHEMA AND PURPURA •OTHER SYMPTOMS INCLUDE FEVER, NAUSEA AND VOMITING
○ Basal cell carcinoma: MOST COMMON FORM OF SKIN CANCER•AFFECTS LIGHT SKINNED INDIVIDUALS BETWEEN 40-80•LOCALLY INVASIVE AND RARELY METASTASIZES •MORE COMMON IN MALES THAN FEMALES •NODULAR PIGMENTED LESION WITH DEPRESSED CENTER AND ROLLED BORDERS AND/OR CENTRAL ULCERATION IN AREAS OF SUN OR UV EXPOSURE
○ Squamous cell carcinoma: 2ND MOST COMMON SKIN CANCER•INVASIVE CANCER ON HEAD, NECK FROM EXCESS SUN OR UV EXPOSURE •MOST COMMON IN INDIVIDUALS WITH BLUE EYES, AND CHILDHOOD FRECKLING OVER 50 YEARS •MEN MORE COMMONLY AFFECTED THAN WOMEN •AEB RED, SCALY PATCH WITH SHARPLY DEMARCATED BORDER •LESION IS SOFT, MOBILE AND SLIGHTLY ELEVATED AND MATURES TO A CENTRAL ULCER WITH SURROUNDING REDNESS
○ Melanoma: MOST SERIOUS FORM OF SKIN CANCER •RESPONSIBLE FOR MAJORITY OF SKIN CANCER RELATED DEATHS •TYPICALLY ARISE FROM NEVI •ABCDEF ASSESSMENT •LESION MAY HAVE FLAKING, SCALING, BE P BROWN, PINK OR PURPLE WITH MIXED PIGMENTATION
○ Kaposi sarcoma: DEVELOPS IN CONNECTIVE TISSUE (CARTILAGE, BONE, FAT, MUSCLE, BLOOD VESSELS OR FIBROUS TISSUES)•AFFECTS THOSE WITH ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) OR DRUG INDUCED IMMUNOSUPPRESSION•APPEARS AS DARK BLUE-PURPLE MACULES, PAPULES, NODULES AND PLAQUES •LESIONS EVENTUALLY SPREAD TO TRUNK, ARMS NECK FACE AND ORAL MUCOSA •PAIN AND PRURITUS ARE PRESENT
○ Ecchymosis: (BRUISE)•DISCOLORATION OF SKIN CAUSED BY BLOOD SEEPING INTO TISSUE AS RESULT OF TRAUMA •1-2 DAYS PURPLE TO DEEP BLACK •3-6 DAYS GREEN TO BROWN •6-15 DAYS TAN TO YELLOW (FADING)•LOOK FOR PATTERNS SUCH AS LOOP PATTERN (CORD HITTING)
○ Bites: ALWAYS INTENTIONAL AND COMMONLY ASSOCIATED WITH ABUSE•OVOID WITH TOOTH IMPRINTS MAY OR MAY NOT BREAK SKIN •NOTE SIZE TO DETERMINE IF BY CHILD OR ADULT •INFANT AND CHILDREN COMMONLY ON BUTTOCKS/GENITALS
○ Burns: FREQUENTLY ASSOCIATED WITH ABUSE •MOST COMMON IS IMMERSION BURN •“GLOVE” OR “STOCKING” PATTERNS •CONTACT BURN- LEAVE IMPRESSION OF OBJECT (CIGARETTE, LIGHT BULB, ETC.) •ACCIDENTAL BURNS LEAVE GLANCING BURN PATTERN WITH NON UNIFORM PATTERN
○ Pediculosis: (LICE)•PARASITES THAT INVADE SCALP, BODY OR PUBIC HAIR •PEDICULOSIS CORPORIS- BODY LICE •PEDICULOSIS PUBIC-PUBIC LICE •SPREAD THROUGH PERSON-TO PERSON CONTACT •ASSESSMENT•SMALL VISIBLE NITS (EGGS) AT BASE OF HAIR SHAFT •SKIN IS RED AND EXCORIATED
○ Alopecia areata: ALOPECIA AREATA •CHRONIC INFLAMMATORY DISEASE OF HAIR FOLLICLES •UNKNOWN CAUSE- BELIEVE AUTOIMMUNE DISORDER, METABOLIC DISEASE AND STRESSFUL EVENTS •MULTIPLE ROUND PATCHES OF HAIR LOSS•POORLY DEVELOPED SHAFT BREAKS AND GROWS BACK IN 3-4 MONTHS (SOME SUFFER TOTAL SCALP HAIR LOSS)
○ Onychomycosis: FUNGAL INFECTION OF NAIL PLATE CAUSED BY TINEA UNGUIUM •OCCURS IN UP TO 18% OF POPULATION IN GIVEN AREAS NAIL PLATE TURNS YELLOW OR WHITE AS HYPERKERATOTIC DEBRIS ACCUMULATES NAIL EVENTUALLY SEPARATES FROM NAIL BED AND NAIL PLATE CRUMBLES
○ Paronychia: ACUTE OF CHRONIC INFECTION OF CUTICLE •USUALLY CAUSED BY STAPH OR STREP BUT CANDIDA MAY ALSO BE CAUSATIVE ORGANISM •RAPID ONSET OF VERY PAINFUL INFLAMMATION AT BASE OF NAIL ABSCESS MAY FORM •INFLAMMATION DEVELOPS SLOWLY USUALLY STARTING AT NAIL BASE AND WORKS ALONG SIDE OF NAILS•FREQUENT EXPOSURE TO MOISTURE IS RISK FACTOR
○ Ingrown Toenail: COMMON PROBLEM •LATERAL NAIL GROWS INTO SKIN •USUALLY ASSOCIATED WITH GREAT TOE •CAUSED BY CUTTING NAIL TOO FAR DOWN SIDES, SHOES TOO TIGHT OR INJURY •REDNESS, PURULENT DRAINAGE (ACUTE INFECTION)
Module 4: Cardiovascular
Chapter 12: Cardiovascular
● Review the anatomy and physiology of the cardiovascular system.
○ The anatomy of the cardiovascular system includes the heart, blood vessels
○ The cardiovascular system transports oxygen, nutrients, and other substances to body tissues and metabolic waste products to the kidneys and lungs. This dynamic system is able to adjust to changing demands for blood by constricting or dilating blood vessels and altering the cardiac output.
● Describe the locations of assessment for the following pulses:
○ Temporal Pulse
■ not routinely assessed
■ Lateral side of each eyebrow
■ Assess perfusion and pain
○ Carotid Pulse
■ used in CPR assessments for adults
■ Medial edge of sternocleidomastoid muscle in lower third of neck
■ Palpate 1 at a time to avoid reducing blood flow to brain
■ Nursing Dx Example: Decreased Cardiac Output r/t altered afterload (decreased peripheral pulses) AEB pulses of 1+ in dorsalis pedis
○ Brachial Pulse
■ used in CPR and cap refill for infants/small children
■ Palpate groove between biceps and triceps just medial to bicep tendon at the antecubital fossa
○ Radial Pulse
■ Thumb side of forearm at the wrist
■ Assess together to assess equality
○ Ulnar Pulse
■ When radial is difficult to assess or injured
■ Located on medial side of forearm
○ Popliteal Pulse
■ (Advanced Practice)
■ Artery behind the knee to assess perfusion
■ Place patient in prone position with leg slightly flexed
○ Posterior Tibial Pulse
■ Inner aspect of ankle below and slightly behind the medial malleolus
○ Dorsalis Pedis Pulse
■ Dorsum of foot between extension tendons of 1st and second toes
● Describe the process for auscultation of bruits in the carotid artery.
○ Bruits
■ low-pitched blowing sounds usually heard during systole that indicate occlusion of the vessel (occlusion of a carotid artery may impair perfusion of the brain and increase the risk for TIA, transient ischemic attack)
■ perform when the patient has a h/o atherosclerosis, dizziness, or syncope
○ Procedure:
■ Use the bell of the stethoscope to auscultate the carotid artery
■ Ask the patient to hold his or her breath while you listen (Fig. 12-34).
■ Finding: You should hear no sound over these arteries.
● Describe the process for assessment of the jugular vein for pulsations.
○ Expected Finding:
■ Elevate HOB 30-45 degrees
● Can be as high as 90 degrees if venous pressures is elevated
■ Elevate chin slightly and tilt head away from side being examined
■ Use penlight to create tangential light
■ Observe for pulsations (expected), shouldn’t be able to visualize vein itself
○ Unexpected Findings:
■ Right-sided heart failure
● Irregular rhythms
● Prominent waves
● Describe the expected heart rate findings for the rate, rhythm, amplitude, and contour.
○ Rate:
■ Newborn 120-160 beats/min
● Faster rate when awake
● Increases on inspiration
● Slower rate when sleeping
● Decreases on expiration
■ Toddler 90-140 beats/min
■ School age child 75-100 beats/min
■ Adolescent 60-90 beats/min
■ Adult- 60-100 beats/min
● Women faster than men by 5-10 beats/min
● Athletic individuals may be as low as 50 beats/min
○ Rhythm
■ Expect equal spacing between beats
○ Pulse Amplitude
■ 0+ absent
■ 1+ diminished (barely palpable)
■ 2+ normal
■ 3+ full volume
■ 4+ full volume, bounding hyperkinetic
■ (force of beat should not alter with respiratory cycle)
○ Contour
■ Smooth and rounded pulse strokes
■ Nursing Diagnosis Example: Decreased Cardiac Output r/t altered heart rate/rhythm AEB HR 55 or 102
● Review blood pressure assessment.
○ Expected
■ Newborn
● Systolic range 60-90
● Diastolic range 20-60
■ Toddler
● Systolic range 80-112
● Diastolic range 50-80
■ School age
● Systolic range 82-120
● Diastolic range 54-80
■ Adult
● Systolic < 120 mmHg
● Diastolic < 80 mmHg
● Pulse pressure should be 30-40 mmHg
■ Nursing Dx Example Elevations: Decreased Cardiac Output r/t altered afterload (increase in peripheral vascular resistance) AEB Systolic BP of 140 and diastolic BP of 88
■ Nursing Dx Example Decreases: Decreased Cardiac Output r/t altered afterload (decrease in peripheral vascular resistance) AEB SBP of 90
● Describe the assessment for orthostatic hypotension.
○ Orthostatic Hypotension
■ Changes in B/P greater than 20 mmHg when changing positions
■ Generally associated with fluid volume deficit, antihypertensive medications or prolonged bed rest
● Review assessment technique for skin turgor and extremity symmetry.
○ Extremities:
■ When one arm is larger in circumference than the other, it could be caused by lymphedema
■ When the skin does not fall back into place, or tenting, indication of reduced fluid in the interstitial space from fluid volume deficit
○ Procedure:
■ Inspect the upper extremities comparing the size and proportion
■ Pinch an area of the skin and release the skin; should return into place
■ Findings: limbs should appear symmetric; skin turgor should be elastic
● Describe the assessment process for edema and subsequent documentation.
○ Edema:
■ When edema is found, notice if it is unilateral or bilateral, the consistency is soft, firm or hard; or there is tenderness
■ When the indentation of the thumb or finger remains in the skin, or pitting edema, it is an indication of excess fluid in the interstitial space
● seen in venous thromboembolism (VTE) and venous insufficiency
○ Process:
■ press down on bony prominence, notice if indentation remains
● Review process for capillary refill
○ Capillary refill
■ Gentle pressure on nail bed
■ Assess brachial/femoral pulses for cap refill in infants
■ Should blanch and refill <2 sec.
■ Nails should be 160 degree
● Describe the significance of hair distribution, skin temperature, nail bed angles, superficial veins and gross sensation during the cardiovascular assessment process.
○ Abnormalities of integrity, color, temperature, capillary refill, and nail color and angle are similar to those described for the upper extremities.
○ Marked pallor or mottling when the extremity is elevated or any ulcerated digit tips may require further evaluation.
○ Arterial insufficiency may cause a decrease in or lack of hair peripherally or skin that appears thin, shiny, and taut.
○ Varicose veins appear as dilated, often tortuous veins when legs are in a dependent position.
○ Abnormalities include pain on palpation or the sensation of “stocking anesthesia,” wherein the legs feel numb in a pattern resembling stockings.
○ The skin should be intact, with color appropriate for race.
○ The skin should feel warm.
○ Capillary refill should be 2 seconds or less.
○ Women who do not shave their legs and men should have hair evenly distributed on upper and lower legs.
○ Nails should be pink, with an angle of 160 degrees at the nail bed.
○ Veins should not be visible.
○ Sensation of the legs should be present without tenderness or numbness.
● What is the significance of impaired peripheral pulses?
○ Impaired peripheral pulses may indicate arterial insufficiency.
● Be familiar with the topographic landmark abbreviations.
○ Cardiac Landmarks:
■ Aortic- 2nd ICS RSB
■ Pulmonic- 2nd ICS LSB
■ Erb's Point-3d ICS LSB
■ Tricuspid- 4th ICS LSB
■ Mitral- 5th ICS MCL
● Describe the differences between lift, heave, thrill and retraction.
○ Lift
■ A lift feels like a more sustained thrust than an expected apical pulse and is felt during systole.
○ Heave
■ A heave is a more prominent thrust of the heart against the chest wall during systole.
■ Lifts and heaves may occur from left or right ventricular hypertrophy caused by increased workload.
○ Thrill
■ A thrill is a palpable vibration over the precordium or artery: it feels like a fine, palpable, rushing vibration.
■ A thrill is associated with a loud murmur.
○ Retraction
■ a visible sinking in of tissues between and around the ribs.
■ Retraction begins in the intercostal spaces
■ It occurs with increased respiratory effort.
■ If additional effort is needed to fill the lungs, supraclavicular (above the clavicle) and infraclavicular (below the clavicle) retraction may be seen.
● Describe the location of the apical pulse.
○ Inspection
■ Rounded, symmetrical (Adults and Pediatric)
■ Slight retraction medial to left MCL at 4-5th ICS for Adults and Peds
● Examine 1st 24 hours of birth
● Examine day 2-3 to assess changes from fetal to systemic/pulmonary circulation
○ Unexpected Findings:
■ Apical pulse –moves laterally in ventricular hypertrophy (myocardium enlargement)
■ PMI down and medial in COPD (r/t overinflated lungs)
■ Apical pulsation after exertion in hyperthyroidism, left ventricular hypertrophy
● Describe the location, pitch, and pathophysiology of S1 and S2.
○ LUB
■ Closing of mitral (M1) and tricuspid (T1) valves
■ indicates beginning of systole
■ Lower in pitch than S2
■ Louder at apex
○ DUB
■ Closing of aortic (A2) and pulmonic (P2) valves
■ Indicates beginning of diastole
■ Higher in pitch than S1
■ Louder at base
● Describe the significance of abnormal heart sounds S3 and S4? When are these normal and/or abnormal? What disease process can they indicate?
○ S3:
■ During diastole, when 80% of the blood in the atria rapidly fills the ventricles, a third heart sound may be heard (S3). It is often heard at the apex. An S3 occurs after the S2 and lasts about the same time as it takes to say “me too.’’ The “me’’ is the S2, and the “too’’ is the S3. An S3 is normal in children and young adults. However, when an S3 is heard in adults over 30 years of age, it signifies fluid volume overload to the ventricle that may be caused by heart failure or mitral or tricuspid regurgitation.
○ S4
■ At the end of diastole, when atrial contraction completes the filling of the ventricle, a fourth heart sound may be heard (S4). An S4 occurs just before the S1 and lasts about the same time as it takes to say “middle.’’ The “mi’’ is the S4, and the “ddle’’ is the S1. An S4 is normal in children and young adults. However, when an S4 is heard in adults over 30 years of age, it signifies a noncompliant or “stiff’’ ventricle. Hypertrophy of the ventricle precedes a non-compliant ventricle. CAD major cause.
● What is a heart murmur? What’s the difference between a systolic and diastolic murmur?
○ Systolic Murmur
■ A murmur occurring during the ventricular ejection phase of the cardiac cycle is termed a systolic murmur. Most systolic murmurs are caused by obstruction of the outflow of the semilunar valves or by incompetent atrioventricular (AV) valves. The vibration is heard during all or part of systole. Other causes of systolic murmurs are structural deformities of the aorta or pulmonary
○ Diastolic Murmur
■ A murmur occurring in the filling phase of the cardiac cycle is termed a diastolic murmur. Incompetent semilunar valves or stenotic AV valves create diastolic murmurs. These murmurs almost always indicate heart disease. Early diastolic murmurs usually result from insufficiency of a semilunar valve or dilation of the valvular ring. Mid- and late-diastolic murmurs are generally caused by stenosed mitral and tricuspid valves that obstruct blood flow.
● List the information that needs to be included in the documentation of a heart murmur.
○ When you identify a heart murmur, consider the following for documentation:
■ Timing and Duration
● At what part of the cycle is the murmur heard?
● Is it associated with S1 or S2, or is it continuous?
■ Pitch
● Low pitches are best heard with the bell of the stethoscope.
■ Quality
● refers to the type of sound including a harsh sound; a raspy, machinelike sound; or a vibratory, musical, or blowing sound
■ Intensity
● Murmur intensity refers to how loud the murmur is:
○ Grade I is barely audible in a quiet room.
○ Grade II is quiet but clearly audible.
○ Grade III is moderately loud.
○ Grade IV is loud and associated with a thrill.
○ Grade V is very loud, and a thrill is easily palpable.
○ Grade VI is very loud, and a thrill is palpable and visible.
■ Location
● Where is the sound heard loudest? Most often it is over one of the five anatomic landmarks used to auscultate heart sounds
■ Example of Documentation: S1, grade II, low-pitch murmur auscultated at fifth ICS, MCL. No thrill palpable.
● Describe the basis of ECG tracings.
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● Describe the follow up assessment required when asymmetry is noted in the upper or lower extremities.
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● What is the significance of unilateral asymmetry versus bilateral edema?
○ Edema of both legs may be caused by fluid overload from systemic disease (e.g., heart failure, renal failure, or liver disease). Unilateral edema of an extremity may be lymphedema caused by occlusion of lymph channels (e.g., elephantiasis or trauma) or surgical removal of lymph channels (e.g., after mastectomy). Localized edema of one leg may be caused by venous insufficiency from varicosities or thrombophlebitis.
● What assessment is done to evaluate the competence of the venous valves? What are the expected versus the abnormal findings?
○ The Trendelenburg’s test evaluates the competence of venous valves and is performed on patients who have varicose veins. With the patient lying supine, the APRN lifts one leg to allow veins to empty and then helps the patient to stand. The procedure is repeated with the other leg. Competent veins fill slowly, while those with varicosities fill rapidly.
● How do you calculate the ankle brachial index (ABI)? What is the significance of an ABI of less than 0.4?
○ ABI, Ankle Brachial Index
■ estimate arterial occlusion, also known as the arm-to-ankle index, AAI
■ when the patient has peripheral arterial disease, the patient has impaired peripheral perfusion that is reflected in a lower systolic pressure in the leg than the arm, which reveals an ABI less than normal
○ Findings:
■ >1 is normal
■ 0.9 to 0.99 indicates some narrowing of arteries (borderline)
■ 0.80 to 0.89 indicates early stages of PAD
■ 0.5 to 0.79 indicates moderate PAD
■ Less than 0.4 indicates severe PAD
■ Severe PAD may lead to ischemia
○ Procedure:
■ ankle systolic blood pressure/brachial systolic blood pressure
■ With the patient in a supine position, take the brachial blood pressure in both arms using Doppler sound
■ Apply the blood pressure cuff above the ankle to measure the systolic pressure of the posterior tibial pulses using the Doppler
● Have a basic understanding of the following common problems and conditions
○ Valvular heart disease
■ r/t disorder of a heart valve (congenital or acquired)
■ AEB: stenotic valve (or)-does not open completely
■ AEB: incompetent valve Does not close completely
■ Can be caused by rheumatic fever, and endocarditis (acquired condition)
○ Angina pectoris
■ ischemia of the myocardium
■ r/t occlusion of the coronary arteries (atherosclerosis)
■ AEB: chest pain lasting 5-15 minutes that subsides with nitroglycerin
■ AKA stable angina
○ Acute coronary syndrome
■ r/t prolonged ischemia
■ AEB: new onset chest pain at rest
● Women atypical symptoms: shortness of breath, fatigue, indigestion, and anxiety
● AKA unstable angina
○ Myocardial infarction
■ r/t sustained ischemia resulting in myocardial cell death
■ AEB: patient statement of chest pain 10/10, that radiates to left shoulder, arm, jaw lasting longer than 5 minutes and not relieved by rest or nitroglycerin
■ dysrhythmias are common
■ Heart sounds sound distant with thread pulse
○ Left ventricular failure
■ r/t increased resistance (aortic stenosis, hypertension)
■ r/t weakening of left ventricle myocardial cell death (MI)
■ Blood back into left atrium and into pulmonary capillaries causing pulmonary edema
■ AEB: fatigue, shortness of breath, orthopnea, dyspnea on exertion, paroxysmal nocturnal dyspnea, displaced PMI, palpable thrill, S3, and systolic murmur at apex bilateral crackles
○ Right ventricular failure
■ Caused by hypertrophy from pulmonary hypertension
■ Can be caused by necrosis of MI
■ Failure of right ventricle to pump blood to pulmonary arteries
■ Black flow into superior and inferior venae cavae
■ If caused by pulmonary disease (like COPD) is known as cor pulmonale
■ AEB: Elevated jugular venous pressure, peripheral edema S3, at lower left sternal border
■ AEB: Systolic murmur and weight gain
○ Infective endocarditis
■ r/t infection of endothelial layer of heart including cardiac valves
● Endocardial surface is damaged by turbulent blood flow as result of valvular heart disease (congenital lesion) or direct injury from IV lines, injections, cardiac catheterization, or artificial valves
■ AEB: development of murmur in presence of damage
● Heart sounds are normal during early infection
○ Pericarditis
■ Inflammation of the parietal and visceral layers of the pericardium and outer myocardium
● Idiopathic, MI, uremia, cancer, trauma, infection, cardiac surgery
■ AEB: pericardial friction rub and chest pain
● Pericardial friction rub is best heard with patient leaning forward at the 2nd, 3d, or 4thICS at LSB or apex, louder on inspiration
● Pain is described as sharp pleuritic pain aggravated by deep breathing lying supine or coughing
○ Hypertension (be familiar with classifications)
■ Classifications:
● Normal
○ Systolic: <120 AND
○ Diastolic: <80
● Prehypertension
○ Systolic: 120-139 OR
○ Diastolic: 80-89
● Stage 1 Hypertension
○ Systolic: 140-159 OR
○ Diastolic: 90-99
● Stage 2 Hypertension
○ Systolic: >160 OR
○ Diastolic: >100
○ Venous thrombosis and thrombophlebitis
■ A thrombus (clot) develops in the vein
■ Thrombophlebitis- inflammation of vein (may be accompanied by a clot)
■ R/T Triad of venous thrombosis (venous stasis, damage to the inner layer of veins, and hypercoagulability
■ AEB: dilated superficial veins, edema, redness and increased circumference of extremity, warmth, tenderness
■ Veins may be visible and palpable
○ Aneurysm
■ Localized dilation
■ R/T weakness in arterial wall
■ Can occur anywhere along the aorta, iliac and cerebral vessels
■ AEB: depends on location
● Thoracic-asymptomatic with deep diffuse chest pain (in some)
● Aorta and Aortic arch-hoarseness from pressure on laryngeal nerve
● Abdominal
○ Most common
○ Can be asymptomatic
○ Thrill or bruit noted
● Cerebral- depend on size and location
