Health Assessment: Skin and Ear Exams

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Questions and Answers

What does the PERRLA assessment indicate about a patient?

Pupils' reactivity and equality, indicating potential brain damage (correct)

The patient's ability to see colors

General eye health status

The size of the pupils only

Which symptoms would you expect in a patient suffering from liver failure?

Elevated blood pressure and anxiety

Jaundice and yellowing of skin and eyes (correct)

Severe headache and dizziness

Increased appetite and weight gain

What visual acuity is considered an expected finding on a Snellen chart?

20/20 vision (correct)

20/40 vision

20/50 vision

20/30 vision

What does an Ishihara test assess?

Color vision deficiency Signup and view all the answers

Which of the following is a common sign of potential abuse when assessing a patient's skin?

Bruising on upper arms and thighs Signup and view all the answers

What would be an unexpected finding when palpating the thyroid during an assessment?

Palpable but not movable Signup and view all the answers

Which of the following is NOT a potential cause of conductive hearing loss?

Optic nerve damage Signup and view all the answers

Which cranial nerve is responsible for facial sensations and movement of the jaw?

Trigeminal nerve Signup and view all the answers

During a Weber test, an unexpected finding would be:

Sound heard more in one ear than the other Signup and view all the answers

What assessment would indicate dehydration in a patient?

Pale or white skin turgor Signup and view all the answers

Which bony prominence is NOT typically associated with a risk of pressure ulcers?

Fingers Signup and view all the answers

Which category is NOT included in the Braden Scale for assessing the risk of skin breakdown?

Dietary preferences Signup and view all the answers

What should be done every two hours to prevent pressure ulcers?

Change the patient's position Signup and view all the answers

What is the correct way to pull the pinna for an adult during a tympanic temperature examination?

Up and back Signup and view all the answers

What is a common indication of chronic hypoxia as observed through fingernails?

Clubbing Signup and view all the answers

Which of the following is NOT a characteristic of expected findings in melanoma?

Well-defined borders Signup and view all the answers

What does a decrease in skin moisture and elasticity indicate in older adults?

Potential skin issues Signup and view all the answers

Which of the following findings might indicate an infection in a wound?

Purulent drainage Signup and view all the answers

What is an expected finding in the integumentary system of older adults?

Thinning hair or hair loss Signup and view all the answers

Which of the following is a measure to prevent melanoma?

Wearing sunscreen Signup and view all the answers

What might a normal angle of fingernails be characterized as?

Convex, 160 degrees Signup and view all the answers

Which of the following foot care practices is recommended for diabetic patients?

File nails straight to prevent injuries Signup and view all the answers

What characterizes stage 2 pressure ulcers?

Partial thickness skin breakdown of epidermis and dermis Signup and view all the answers

Which description correctly defines a type of rash expected in herpes zoster?

Vesicular lesions following nerve tracks Signup and view all the answers

When assessing mucous membranes on dark-skinned patients, which area is best for examination?

Tongue and gingiva Signup and view all the answers

What does the term 'unstageable' mean in the context of pressure ulcers?

Unknown depth of injury that requires debridement Signup and view all the answers

Which of the following skin functions is NOT accurately described?

Absorbs calcium directly for metabolic use Signup and view all the answers

How is edema classified, when assessing its severity?

On a scale of 1 to 4 indicating depth and skin response Signup and view all the answers

Which characteristic feature is associated with stage 4 pressure ulcers?

Full tissue loss with exposed bone or muscle Signup and view all the answers

What does tenting of the skin indicate?

Possible dehydration Signup and view all the answers

Which drainage characteristic is described as having a pink tinge?

Sanguineous Signup and view all the answers

How should temperature be assessed when palpating?

Using the pads of the fingers Signup and view all the answers

What type of skin lesion is a keloid classified as?

Secondary lesion Signup and view all the answers

When assessing capillary refill, what is considered a normal return time?

1-2 seconds Signup and view all the answers

During a neck assessment, what is an unexpected finding?

Limited neck movement Signup and view all the answers

What does cyanosis indicate when assessing skin color?

Blue coloration Signup and view all the answers

What is the recommended method for palpating the frontal sinus?

Pressing firmly in an upward motion just under the eyebrows Signup and view all the answers

Study Notes

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

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Description

This quiz focuses on important health assessment techniques for tympanic temperature and otoscopic examinations, as well as the identification of clubbing of fingernails and melanoma. Understand key findings and preventive measures to ensure accurate assessments. Test your knowledge on these vital health indicators!