Health Assessment: Skin and Ear Exams

Tympanic Temperature/Otoscopic Exam

• Pull the pinna up and back for adults, down and back for children.
• Supplies needed: otoscope
• Expected tympanic membrane findings: pearly gray translucent
• Unexpected tympanic membrane findings: redness, inflammation, drainage, perforations
• Excessive earwax (cerumen) can cause conductive hearing loss

Clubbing of the Fingernails

• Appearance: Enlarged, curved downward
• Indicates: Chronic hypoxia, cystic fibrosis, heart failure, pulmonary disease, COPD
• Expected nail findings: 160-degree angle, convex, rounded, pinkish
• Normal nail angle: 160 degrees

Melanoma

• ABCDE assessment: Asymmetry, Border irregular, Color variations/changing, Diameter less than 6 mm, Evolving (in color and size)
• Prevention measures: Annual checkups, protective clothing, sunscreen, limited sun exposure
• Risk factors: Caucasian ethnicity, family history, UV exposure, certain occupations

Wounds and Signs of Infection

• Signs of infection: Inflammation, redness, elevated white blood cell count, purulent drainage, pain, fever, low blood pressure (< 90 systolic/60 diastolic)
• Signs of wound healing: Scabbing, adhesion, dryness, itching, no erythema or edema, WBC trending down, decreased pain

Older Adult and Integumentary/HEENT System

• Expected findings: Loss of subcutaneous fat, moisture, and elasticity, facial bones more prominent, difficulty hearing high-frequency sounds, liver spots
• Unexpected findings: Redness of lower extremities, bruises, edema, lesions, hematomas, scales, pressure ulcers
• HEENT: Decreased vascularity, loss of sweat glands, thinning hair/hair loss, decreased sense of taste, decreased vision

Lymph Node Examination

• Palpation technique: Pads of index and middle fingers in a circular motion with gentle pressure
• Expected findings: Non-palpable, non-tender
• Unexpected findings: Palpable and movable
• Thyroid palpation: Feel for smooth, non-tender thyroid during swallowing

Hearing Loss

• Assessment questions: Do you wear hearing aids? Can you hear me? Recent change in hearing? History of ear infections?
• Causes of conductive hearing loss: Excessive cerumen buildup, occupational noise exposure, headphone use, trauma, middle ear infections, Q-tip usage, sinus infections

Cranial Nerves: I, III, IV, VI, VIII, XI, XII

• I. Olfactory (smell): Test by closing eyes and identifying odors
• II. Optic (visual acuity): Tested with Snellen chart
• III. Oculomotor (eye movement, raise eyelid): Tested with the "8" or "H" test
• IV. Trochlear (downward/inner eye movement): Tested with the "8" or "H" test
• V. Trigeminal (facial sensation/biting, chewing): Tests for tongue movement
• VI. Abducens (lateral eye movement): Tested with the "8" or "H" test
• VII. Facial (facial expressions/taste):
• VIII. Vestibulocochlear (balance and hearing): Whisper test
• IX. Glossopharyngeal (gag reflex, swallowing/taste)
• X. Vagus (gag reflex/sensation of pharynx and larynx)
• XI. Accessory (shoulder/neck movement): Shrug shoulders and turn head
• XII. Hypoglossal (tongue movement/speech)

Weber Test

• Conductive hearing loss assessment: Tuning fork placed on top of head or base
• Expected finding: Hearing on both sides equally
• Unexpected findings: Hearing on one side only or not at all

Integumentary Signs of Dehydration

• Tenting, pale mucous membranes, dry and chapped lips, back of hand and clavicle
• Causes: Lack of fluids, exercise, vomiting/diarrhea, certain medications (diuretics)

Bony Prominences

• Locations: Ankles, knees, shoulders, back of head, elbows
• Pressure ulcer preventative measures: Turning every 2 hours, reducing moisture, assisted devices, elevating heels
• At-risk individuals: Elderly, unconscious, chronic health issues/infection

Braden Scale

• Used to assess risk for skin breakdown
• Categories: Sensory perception, moisture, activity, mobility, nutrition, friction/shear
• Higher risk: Younger individuals, bedridden
• Lower risk: Older individuals, mobile

Liver Failure

• Expected findings: Jaundice (yellowing of eyes, skin, and mucous membranes), yellowing of the palate

PERRLA - Pupils Equal Round Reactive to Light and Accommodation

• Assesses: Pupil reactivity and equality, potential for brain damage
• Consensual constriction: Both pupils constrict simultaneously when light is shone into one eye
• Accommodation: Pupils constrict when focusing on near objects and dilate when focusing on distant objects

Signs of Possible Abuse

• Bruises, bite marks, belt marks, burns, deformities that don't match the injury

Snellen Chart

• Used to assess visual acuity
• 20/20 is an expected finding
• 20/40 means the patient needs to be 20 feet away to see letters that a person with normal vision can see at 40 feet
• First number: Distance the patient is from the chart
• Second number: Distance a person with normal vision can see the letters
• Remove reading glasses before testing

Rosenbaum Eye Chart

• Hold 14 inches away from the client
• Used to assess presbyopia (impaired near vision)

Ishihara Test

• Used to assess color vision

Foot Care for Diabetic Patients

• Use water-based lotions (not between toes), avoid flip flops, file nails straight, daily checks, no soaking feet, dry between toes, wear closed-toed shoes

Herpes Zoster (Shingles)

• Priority nursing diagnosis: Pain management
• Expected rash: Vesicular lesions along nerve tracks, contagious when open or blistered

Functions of the Skin

• Waterproof, protective, adaptive
• Protection from the environment (first line of defense)
• Prevents penetration
• Perception
• Temperature regulation
• Identification
• Communication
• Wound repair
• Absorption and excretion
• Converts vitamin A to vitamin D (vitamin D synthesis)
• Necessary for the intestines to absorb calcium

Staging of Pressure Ulcers

• Stage 1: Non-blanchable erythema, intact skin, darker skin tones may have blue or purple hue
• Stage 2: Partial-thickness skin breakdown of the epidermis and dermis, superficial, red-pink wound bed
• Stage 3: Full-thickness skin loss, damage to subcutaneous tissue, deep without exposed muscle or bone
• Stage 4: Full-thickness tissue loss, necrosis, slough, black scabbing, tunneling or undermining
• Unstageable: Unknown depth or injury, requires debridement before healing can begin
• DTI (Deep Tissue Injury): Discoloration of intact skin, damage to underlying skin

Edema Assessment Scale

• 1+ (Trace): 2 mm indentation with rapid skin response
• 2+ (Mild): 4 mm indentation with 10-15 second response
• 3+ (Moderate): 6 mm indentation with prolonged skin response
• 4+ (Severe): 8 mm indentation with prolonged skin response

Thyroid Gland Assessment

• Hyperextend the neck and ask the client to swallow

Temperature Assessment by Palpation

• Use the pads of the fingers

Drainage Characteristics

• Serous: Clear
• Sanguineous: Pink tinge
• Purulent: Pus with odor

Skin Turgor

• Assesses hydration status
• Normal: Skin returns to its position quickly
• Abnormal: Skin returns slowly (indicates dehydration)
• Assessment locations: Clavicle for older adults, back of hand for younger adults

Primary & Secondary Skin Lesions

• Primary lesions (arise from normal skin)
  • Nodules, pustules, atrophy, wheals, plaques, patches, tumors, vesicles, bullas, urticaria (hives)
• Secondary lesions (arise from primary lesions)
  • Keloids, crusts, scales, fissures, erosions, scars, atrophic scars

Sinus Palpation

• Palpate frontals: Press firmly in an upward motion just under the eyebrows

Assessing Skin

• Inspection: Color, temperature, hair, lesions, moles, inflammation
• Palpation: General pigmentation, freckles, moles, birthmarks, assess for moisture using finger pads, assess warmth using the dorsal side of the hand

Capillary Refill

• Assess circulation
• Press the fingernail, observe return of blood flow
• Sluggish refill: Takes longer than 1-2 seconds

Neck Assessment

• Expected findings: Normal forward, backward, and side-to-side movement, trachea midline
• Unexpected findings: Shift in trachea, limited neck movement