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Questions and Answers
What should be used as a barrier when applying ice packs or cold therapy?
Which of the following is NOT a characteristic of abnormal moles or nevi as identified by the ABCDE mnemonic?
What is the priority nursing intervention for a suspicious mole?
What is the recommended interval for assessing the site when using ice packs?
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Which symptom is NOT typically associated with dehydration?
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What potential complication is indicated by nail clubbing?
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What intervention is suggested for itchy rashes?
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What is a common risk factor for dehydration related to gastrointestinal losses?
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What is the first action to take when a patient shows signs of dyspnea?
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Which respiratory pattern is characterized by constant deep, rapid breathing without pauses?
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Crackles in the lungs are often associated with which condition?
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What sound is typically heard in patients with narrowed airways during dyspnea?
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In managing a patient with COPD, what is a crucial consideration regarding oxygen administration?
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What should be primarily assessed when a patient complains of dyspnea?
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Which finding could indicate the need for immediate focused assessment?
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What is the recommended intervention for a patient post-operation to prevent pneumonia?
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What is a common misconception regarding exercise-induced bronchospasm?
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What symptom is considered less of a priority compared to abnormal respiratory rates?
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What is a sign of dehydration that can be assessed by pinching the skin below the clavicle?
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Which type of lesion is characterized as large fluid-filled blisters?
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What does a score of 6 indicate on the Braden Scale for assessing pressure injury risk?
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What intervention is most effective for patients at high risk of pressure injuries?
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What is a typical characteristic of stage 1 pressure injury?
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What symptom is NOT typically associated with a migraine headache?
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Which cranial nerve is responsible for the sense of smell?
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What does PERRLA stand for in assessing pupils?
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What is the primary goal of assessing eyes during an examination?
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How should a healthcare provider first assess a patient suspected of having hearing loss?
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What intervention should be avoided when caring for skin at risk of pressure injuries?
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In eye assessments, what does a Snellen chart primarily measure?
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What should you expect when a patient is experiencing acute facial weakness and has a potential stroke?
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Which cranial nerve is tested by assessing the uvula rise when the patient says 'ah'?
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What is the priority action to take if a patient's SpO2 levels are low?
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Which of the following actions may be delegated to unlicensed assistive personnel (UAP)?
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When assessing a chief complaint, what should a nurse prioritize using?
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What is recommended for patients requiring nasal cannula oxygen during ambulation?
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What is NOT a priority when dealing with respiratory issues in a patient?
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Which data type should be eliminated when the question specifies subjective data?
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In nursing practice, what should be done after performing all appropriate immediate interventions?
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For a patient with low SpO2 but no history of COPD, what is the first priority intervention?
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Which of the following skin assessments is not typically indicative of abuse?
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In relation to the Snellen chart, what does a reading of 20/40 indicate?
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What issue does PERRLA most directly assess during an examination?
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What symptom would best indicate liver failure during a physical assessment?
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Which change is associated with aging and is reflected in the skin's appearance?
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What characteristic is most indicative of melanoma severity?
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Which of the following findings could suggest conductive hearing loss due to excessive ear wax?
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What is the expected angle of curvature for normal fingernails?
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Which symptom is indicative of infection in a wound?
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What is a common change in the integumentary system among older adults?
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Which cranial nerve is primarily evaluated by testing a patient's ability to hear high-frequency sounds?
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Which of the following is a sign of proper wound healing?
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What are the characteristics of clubbing of the fingernails?
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How is skin turgor primarily assessed in older adults?
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Which type of drainage is characterized by a clear appearance?
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Which finding would indicate a potential issue during a neck assessment?
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What does tenting of the skin suggest in a patient?
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When assessing capillary refill, which time frame indicates a potential circulatory problem?
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Which assessment technique is appropriate for assessing moisture levels of the skin?
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Which primary lesion can be described as fluid-filled, varying in size, and potentially indicating a severe dermatological condition?
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Which color change may indicate an oxygen deficiency in the skin?
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Which secondary lesion is characterized by thickened, fibrous tissue?
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Which assessment method is used to palpate the frontal sinus?
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What is the most characteristic sign of stage 2 pressure injury?
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In the assessment of edema, what depth corresponds to a 4+ severity rating?
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Where is the best area to assess mucous membranes for dark-skinned patients?
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Which function of the skin is primarily responsible for temperature regulation?
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What is the defining feature of a stage 3 pressure injury?
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Which of the following statements accurately describes a priority nursing diagnosis for herpes zoster, also known as shingles?
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What does non-blanchable erythema typically indicate about the skin condition?
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What skin change is commonly associated with aging?
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Which stage of pressure ulcers is associated with full tissue loss and necrosis, presenting as slough or eschar?
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Vitamin D synthesis in the skin is essential for what primary bodily function?
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What finding would indicate a potential conductive hearing loss during a Weber test?
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Which cranial nerve is primarily responsible for facial expressions and taste sensation?
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What is a critical preventative measure to avoid pressure ulcers in high-risk patients?
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What assessment question is crucial for evaluating a patient's hearing loss?
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Which integumentary sign is indicative of dehydration during assessment?
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What is a common risk factor for developing significant skin breakdown in elderly patients?
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Which category is NOT included in the Braden Scale for assessing pressure injury risk?
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Which cranial nerve is tested by having the patient identify a smell while their eyes are closed?
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What could lead to impaired balance as assessed by the vestibulocochlear nerve?
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Which aspect of cranial nerve examination is NOT evaluated by the whisper test?
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When performing a tympanic temperature examination on an adult, how should the pinna be pulled?
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What is an expected finding of a healthy tympanic membrane?
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Which condition is indicated by clubbing of the fingernails?
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What is a common characteristic of melanoma according to the ABCDE criteria?
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What signs indicate an infection in a wound?
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In older adults, what is an expected finding in the integumentary system?
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Which finding is considered unexpected in an elderly patient's integumentary assessment?
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What should be assessed to determine the normal angle of fingernails?
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What is the significance of observing jaundice in a patient?
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Which assessment would indicate positive accommodation response in pupils?
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What does a reading of 20/40 on a Snellen chart imply regarding a patient's vision?
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Which phrase best describes consensual constriction of pupils?
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During a skin assessment for signs of possible abuse, which finding is least indicative?
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What does the 'P' in PERRLA stand for?
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In assessing a patient for presbyopia using the Rosenbaum eye chart, what is the expected distance for holding the chart?
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Which symptom is commonly associated with liver failure?
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What is the function of the Ishihara test?
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Which of the following best describes the risk factors for developing pressure injuries?
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What does skin turgor primarily assess in older adults when testing for dehydration?
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Which drainage characteristic is associated with a clear fluid?
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What technique is recommended for assessing capillary refill during a physical examination?
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When inspecting the oral mucous membranes, which characteristic would indicate a sign of concern?
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Which of the following describes a primary lesion?
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What is an unexpected finding when palpating the thyroid during a physical examination?
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Which condition is least likely to cause conductive hearing loss?
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During a cranial nerve assessment, which nerve is examined by testing the movement of the eyes using the H test?
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What indicates a finding of hearing loss during the Weber test?
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Which of the following signs is NOT indicative of dehydration?
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Which of these conditions is a risk factor for developing pressure ulcers?
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What element is NOT measured by the Braden Scale?
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What is expected when palpating bony prominences for pressure ulcer risk?
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Which cranial nerve is primarily responsible for the gag reflex?
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What is a common misconception regarding techniques used to assess skin integrity?
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What is the expected appearance of stage 2 pressure ulcers?
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Which type of edema indicates a skin response of 4+?
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What is a common feature of herpes zoster, also known as shingles?
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Which of the following is NOT a function of the skin?
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In assessing mucous membranes on dark-skinned patients, where is the best location for assessment?
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Which characteristic is associated with stage 3 pressure ulcers?
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What priority nursing diagnosis should be considered for a patient with shingles?
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Which action is recommended for diabetic patients to maintain foot health?
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What does a deep tissue injury (DTI) indicate?
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How should toenails be maintained for diabetic patients?
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Study Notes
Skin, Hair & Nails
- When assessing a rash, use OLDCARTS to gather subjective information, including pain and itching.
- Always wear gloves when assessing skin and make family members wear gloves as well when touching the patient.
- To soothe itchy rashes, discourage scratching and apply a cool cloth.
- Do not apply ice packs directly on the skin.
- Use a cloth or towel as a barrier and assess the site for color, pain, sensation, blisters, etc., every 5-10 minutes.
- Educate patients on the importance of daily sunscreen use.
- Use the ABCDE mnemonic to assess for abnormal moles or nevi, remembering:
- Asymmetry
- Border irregularity
- Color variation
- Diameter greater than 6mm
- Evolving or changing
- Report suspicious moles to the provider promptly.
- Older adults are at increased risk for hair thinning or loss on the head and may develop hair growth in other areas.
- Onychomycosis (nail fungus) is more common in older adults.
- Assess for risk factors for dehydration such as GI losses (emesis & diarrhea), inadequate intake, and medical conditions requiring extra fluids.
- Assess for signs and symptoms of dehydration such as skin tenting, dryness, and poor skin turgor.
- Vesicles are small fluid-filled blisters.
- Bullae are large fluid-filled blisters.
- Macules are small, flat, hypo/hyperpigmented areas.
- Papules are small, raised solid lesions.
- Pustules are pus-filled lesions.
- Patches are large macules, usually erythematous.
- Wheals are erythematous, raised, swollen lesions.
Pressure Injuries
- The Braden Scale is the best tool to assess risk factors for pressure injuries.
- A score of 6 indicates the highest risk and 23 indicates the lowest risk.
- Risk factors for pressure injuries include immobility, poor nutrition, friction/shear, sensory impairments, moisture, and lack of movement.
- Patients with hip fractures are at high risk due to immobility.
- Assess patients for pressure injury risk upon admission.
- Remember the stages of pressure injuries:
- Stage 1: non-blanchable erythema (no open wound)
- Stage 2: superficial ulcer; no involvement of deeper tissues
- Stage 3: involves subcutaneous tissue and may have tunneling or undermining
- Stage 4: involves muscle or bone, very deep, tunneling & undermining
- Assess for signs of healing when evaluating treatment interventions.
- Important interventions for pressure injury prevention & treatment include:
- Keeping the skin clean and dry
- Frequent monitoring and management of incontinence
- Avoiding lotion and ointment on bony prominences
- Checking for incontinence every two hours
- Cleansing with lukewarm water, not hot water
- Avoiding excessive bathing (keep the skin dry)
- Using gentle soap and fully drying the skin
- Avoiding scrubbing the skin and using powders on the skin
- Avoiding briefs for prolonged periods
- Offloading pressure
- Turning and repositioning every two hours while in bed
- Using bed with alternating pressure, heel lift pads, and turning wedge
- Shifting weight every 15 minutes if the patient is sitting in a chair
- Keeping the head of the bed low to offload pressure on the sacrum/coccyx
- Maintaining adequate hydration status
- Providing protein supplements if the patient has poor oral intake or low serum albumin or protein levels.
HEENT
- Priority findings during HEENT assessment include:
- Asymmetry of the face
- Signs of dysphagia
- Unilateral weakness
- Symptoms of stroke
- Cranial trauma or bleed
- Angioedema (swelling around the lips)
- Neck mass or goiter
- Jaundiced sclera
- Migraine headaches should not cause neurologic dysfunction.
- Assess for severity, location, and duration of headaches, as well as contributing factors.
- If episodes are frequent, assess for interference with daily life and functioning.
- Prevention is the goal with frequent migraine episodes (may need preventive medication).
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Cranial Nerve Assessment
- I: Olfactory (Smell)
- II: Optic (Vision)
- III, IV & VI: Oculomotor, Trochlear & Abducens (Eye movements & pupil dilation/constriction)
- V: Trigeminal (Facial sensation & chewing)
- VII: Facial (Facial expressions)
- VIII: Acoustic/Vestibulocochlear (Hearing & balance)
- IX: Glossopharyngeal (Swallow/gag reflex)
- X: Vagus (Digestion & throat sensation)
- XI: Spinal Accessory (Shoulder movements)
- XII: Hypoglossal (Tongue movements)
- The skull should be normocephalic, symmetrical, and nontender.
- The tops of the ears should align with the outer canthus of the eyes.
- Assess for sinus tenderness in the maxillary (cheek below eyes) and frontal (forehead) sinuses.
- Assess the conjunctivae, sclera, iris, eyelids, eyelashes, and ocular movements.
- When assessing for any eye complaint, use a Snellen eye chart to assess far vision.
- Remember the Snellen Eye Chart interpretation:
- Numerator: Distance from chart
- Denominator: Distance at which a normal eye can see
- Normal: 20/20
- Interpretation: The patient can read at 20 feet what an average person can read at [ ] feet.
- Example: Vision 20/40: The patient can read at 20 feet what an average person can read at 40 feet (decreased vision).
- Legal blindness: 20/200
- Assess and document vision for each eye separately and then bilaterally.
- Other vision assessments include the Ishihara chart (color blindness) and Rosenbaum chart (near vision).
- Environmental interventions to promote safety for visual impairments include:
- Avoiding trip hazards (small rugs, cords, clutter)
- Encouraging electronics that read out loud
- Consistent use of eyeglasses, adequate lighting, and a cane
- Cleaning eyeglasses and drying with soft cloths
- Nystagmus is rapid jerky or tremor-like eye movement.
- Diplopia is double vision.
-
PERRLA is evidence of CNs III, IV, and VI but not vision (CN II):
- Pupils
- Equal
- Round
- Reactive to
- Light
- Accommodation
- Inspect and palpate the external ears.
- Conductive hearing loss is caused by excessive cerumen buildup.
- Sensorineural hearing loss is dysfunction of CN VIII and may be associated with tinnitus (ringing in the ears).
- For patients with hearing impairments:
- Assess level of impairment, use of hearing aids, and patient preferences.
- Face the patient and speak slowly. Do not shout at them.
- Assess for hearing aid use, exposure to loud noises, and tinnitus in patients with acute hearing loss complaints.
- Assess for septal alignment, symmetry, color, tenderness, and swelling of the turbinates in the nose.
- Assess for buccal mucosa (mucous membranes, which are the best place to assess for discoloration in dark-skinned patients).
- When assessing the neck, look for masses or a goiter, especially if the patient has difficulty swallowing.
- If a goiter is noted, auscultate for a bruit (do not palpate).
Respiratory
- When assessing for respiratory issues, ask patients to take deep breaths and auscultate breath sounds while they are breathing deeply.
- Inspect the chest and observe for respiratory effort and symmetry of respirations.
- If a patient has a productive cough, assess for sputum color, crackles, and vital signs (RR, SpO2) and encourage coughing and deep breathing.
- Do NOT use cough suppressants.
- Dyspnea is subjective respiratory distress.
- If a patient is experiencing dyspnea, first elevate the head of the bed.
- Kussmaul respirations are constant deep, rapid breaths without pauses.
- Cheyne-Stokes respirations have a progressive increase in respiratory depth and rate followed by a period of apnea.
- Crackles are caused by air passing through secretions and are often heard in pneumonia.
- Wheezing is a high-pitched sound associated with air passing through narrowed airways.
- Rhonchi are louder, deeper sounds than crackles.
- Bronchovesicular breath sounds: heard over the sternum anteriorly and between the scapulae posteriorly.
-
COPD (Chronic Obstructive Pulmonary Disease):
- Avoid over-oxygenating COPD patients -- do NOT administer oxygen if spO2 is not low.
- A barrel chest appearance is considered a normal finding.
- Pursed-lip breathing is encouraged.
-
Asthma:
- Patients may exhibit wheezing and chest tightness.
-
Exercise-Induced Bronchospasm (EIB):
- May exhibit wheezing, chest tightness, and dyspnea.
- Requires follow-up with a provider and might require a prophylactic albuterol inhaler.
- Encourage exercise with appropriate medication.
- Nursing intervention: Encourage the use of an incentive spirometer to prevent atelelectasis and pneumonia.
- Prioritize: When priority findings are present, perform a focused assessment first, before interview or a full head-to-toe assessment.
-
Priority findings:
- RR greater than 22 or less than 12
- Sudden or severe hypoxia, or hypoxia that does not immediately improve with oxygen administration
- Dyspnea (subjective)
- Increased work of breathing (objective)
- HR greater than 110 along with an acute respiratory symptom
- Signs of airway compromise (obstruction or altered mental status)
- Asymmetry of chest expansion or an abnormal breathing pattern
- Crackles in ALL lobes
- While a fever greater than 100.5 degrees Fahrenheit poses a risk for dehydration and difficulty expectorating, abnormal HR, RR, and SpO2 are higher priorities.
- RRT: Use if respiratory distress/hypoxia/airway compromise, etc., is present.
-
Supplemental oxygen:
- Administer only if hypoxia is present and perform the appropriate procedure first.
- Patients who need O2 via nasal cannula require a portable oxygen tank for ambulation, and ambulation should not be discouraged.
Delegation
- You CAN delegate hygiene and ADL assistance to UAP.
- This includes checking for incontinence, but not assessing the patient.
- You CANNOT delegate assessment to UAP, including the use of the Braden tool.
General Tips
- Resist the urge to change your answers.
- Remember to use OLDCARTS when assessing any chief complaint.
- Read the question and answers thoroughly.
- When identifying subjective data, eliminate objective data and vice versa.
Med Math
-
Liters to mL:
- Remember that 1 Liter (L) equals 1,000 milliliters (mL).
- Example: 4.5L = 4,500mL
-
Calculating mcg/dose given an order in mL:
- Example: Order is for 20mL, but the medication comes in 200mcg/5mL. You will give 800mcg/dose.
-
Calculating mL/dose given an order in mg/mL:
- Example: Order is for 1,000mcg, but the medication comes in 2mg/mL. You will give 0.5mL/dose.
-
Kilograms to pounds:
- Remember that 1 kilogram (kg) equals 2.2 pounds (lbs).
- Example: 140 kg = 308 lbs
-
Calculating # tablets/dose while converting mcg to mg:
- Example: Order is for 100mcg, but the medication comes in 0.1mg/tablet. You will give 1 tablet/dose.
Tympanic Temperature and Otoscopic Exam
- Pull the pinna up and back for adults and down and back for children.
- Supplies needed: otoscope.
- Expected findings of the tympanic membrane: pearly gray, translucent.
- Unexpected findings: Redness, inflammation, drainage, perforations.
- Conductive hearing loss can occur with excessive earwax.
Clubbing of the Fingernails
- Appearance: Enlarged, curved downwards.
- Indicates: Chronic hypoxia, conditions like cystic fibrosis, heart failure, pulmonary disease, COPD.
- Expected nail findings: 160 degree angle, convex, rounded, pinkish.
- Normal angle of nails: 160 degrees.
Melanoma
- ABCDE: Asymmetry, Border irregular, Color variations, Diameter greater than 6 mm, Evolving.
- Prevention: Annual checkups, protective clothing, sunscreen, limited sun exposure.
- Risk factors: Caucasian ethnicity, family history, UV exposure, certain occupations.
Wounds
- Signs of infection: Inflammation, redness, elevated white blood cells, purulent drainage, pain, fever, low blood pressure.
- Signs of wound healing: Scabbing, signs of adhesion, dryness, itching, absence of erythema and edema, decreasing white blood cell count, decreased pain.
The Older Adult and the Integumentary/HEENT System
- Expected findings: Loss of subcutaneous fat, decreased moisture and elasticity, prominent facial bones, difficulty hearing high-frequency sounds, liver spots, decreased vascularity, thinning hair or hair loss, decreased sense of taste and vision.
- Unexpected findings: Redness of lower extremities, bruises, edema, lesions, hematoma, scales, pressure ulcers.
- HEENT expected findings: Decreased vision and taste, central lentigines.
- HEENT unexpected findings: Redness of lower extremities, bruises, edema, lesions, hematoma, scales, pressure ulcers.
Lymph Node Examination
- Palpation: Use pads of index and middle fingers to feel in a circular motion with gentle pressure.
- Expected findings: Non-palpable, non-tender.
- Unexpected findings: Palpable nodes should be movable.
- Thyroid examination: Feel for the thyroid while the patient swallows, it should be non-tender and smooth.
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 earwax buildup, occupational exposure, headphone use, trauma, history of middle ear infection, Q-tip usage, sinus infections.
Cranial Nerves
- **Cranial Nerve I (Olfactory): Smell; test by having the patient close their eyes and identify an odor.
- Cranial Nerve II (Optic): Vision; test visual acuity.
- Cranial Nerve III (Oculomotor): Eye movement, raise eyelid; test using the "H" test.
- Cranial Nerve IV (Trochlear): Downward and inner eye movement; test using the "H" test.
- Cranial Nerve V (Trigeminal): Facial sensation, biting, chewing, tongue movement.
- Cranial Nerve VI (Abducens): Lateral eye movement; test using the "H" test.
- Cranial Nerve VII (Facial): Facial expressions, taste.
- Cranial Nerve VIII (Vestibulocochlear): Balance and hearing; test with a whisper test.
- Cranial Nerve IX (Glossopharyngeal): Gag reflex, swallowing, taste.
- Cranial Nerve X (Vagus): Gag reflex, sensation of pharynx and larynx.
- Cranial Nerve XI (Accessory): Shoulder and neck movement; test by having patient shrug shoulders and turn their head.
- Cranial Nerve XII (Hypoglossal): Tongue movement and speech.
Weber Test
- Purpose: Test for conductive hearing loss.
- Procedure: Place a tuning fork on the top of the head or base of the skull.
- Expected findings: Patient hears the sound equally in both ears.
- Unexpected findings: Patient hears the sound in one ear or not at all.
Integumentary Signs of Dehydration
- Signs: Tenting (skin turgor), pale mucous membranes, dry and chapped lips, pale/white skin on the back of the hand and clavicle.
- Causes: Lack of fluids, excessive exercise, vomiting/diarrhea, certain medications (diuretics).
Bony Prominences
- Locations: Ankles, knees, shoulders, back of the head, elbows.
- Pressure ulcer preventative measures: Repositioning every 2 hours, reducing moisture with linen changes and barrier creams, assistive devices to reduce pressure, elevation of heels with pillows.
- At risk individuals: Elderly, unconscious, individuals with chronic health issues or infections.
Braden Scale
- Categories: Sensory perception, moisture, activity, mobility, nutrition, friction/shear.
- Risk factors: 80 or higher indicates less risk, younger age and bedridden status indicates higher risk.
Diabetic Patient Foot Care
- Recommendations: Use water-based lotions (not between toes), avoid flip flops, file nails straight, daily foot checks, avoid soaking feet, ensure toes are dry between them, wear closed-toed shoes.
Herpes Zoster (Shingles)
- Priority nursing diagnosis: Pain management.
- Expected rash: Clusters of vesicular lesions on nerve tracks. Rash is contagious when open or blistered.
Skin Function
- Waterproof barrier.
- Protection from environment - first line of defense.
- Prevents penetration.
- Perception (sensory).
- Temperature regulation.
- Identification.
- Communication.
- Wound repair.
- Absorption and excretion.
- Converts vitamin A to Vitamin D.
- Necessary for intestinal calcium absorption.
Staging of Pressure Ulcers
- Stage 1: Non-blanchable erythema, intact skin (darker skin tones may appear blue or purple).
- 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 of injury, needs debridement to start the healing process.
- Deep tissue injury (DTI): Discoloration of intact skin, damage to underlying skin.
Edema
- Scale: 1-4.
- 1+: Trace, 2 mm indentation, rapid skin response.
- 2+: Mild, 4 mm indentation, 10-15 second skin response.
- 3+: Moderate, 6 mm indentation, prolonged skin response.
- 4+: Severe, 8 mm indentation, prolonged skin response.
Thyroid Gland Assessment
- Procedure: Hyperextend the patient's neck and ask them to swallow.
Assessing Temperature by Palpation
- Method: Use the pads of the fingers.
Drainage Characteristics
- Serous: Clear.
- Sanguineous: Pink tinge.
- Purulent: Pus with odor.
Skin Turgor
- Method: Assess skin turgor by gently pinching the skin on the clavicle (older adults) or the back of the hand (younger adults).
- Normal: Skin returns to its original position quickly.
- Abnormal: Skin returns to its original position slowly.
- Tenting indicates: Dehydration.
Primary Skin Lesions
- Nodules, pustules, atrophy, wheals, plaques, patches, tumors, vesicles, bullae, urticaria (hives).
Secondary Skin Lesions
- Develop from primary lesions: Keloids, crust, scales, fissures, erosions, scars, atrophic scars.
Sinus Palpation
- Use your thumbs to palpate the sinuses.
- Frontal sinus: Press firmly upward just below the eyebrows. Refer to a health assessment manual for specific palpation techniques.
Assessing Skin
- Inspection: Color, temperature, hair, lesions, moles, inflammation.
- Palpation: General pigmentation, freckles, moles, birthmarks.
- Auscultation and percussion are not used for skin assessments.
Skin Color
- Pallor (pale): Loss of color.
- Erythema (reddish): Reddish tone.
- Cyanosis (blue): Blue color.
- Jaundice (yellow): Yellow to yellow-orange color.
Assessing Moisture
- Method: Use fingertips to assess for moisture.
Assessing Temperature
- Method: Use the dorsal side of the hand to assess temperature.
Assessing Capillary Refill
- Procedure: Press on the patient's fingernail and observe how quickly the color returns.
- Normal: Blood flow returns within 1-2 seconds.
- Abnormal: Sluggish blood flow (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.
Liver Failure
- Expected findings: Jaundice (yellowing of the eyes, skin, and mucous membranes), including the palate.
PERRLA
- Purpose: To assess pupillary response to light and accommodation.
- Abbreviation: Pupils, Equal, Round, Reactive to Light, and Accommodation.
- Assessment: Pupils are both reactive and equal, indicating no brain damage.
- Consensual constriction: When light is shone in one eye, both pupils constrict simultaneously.
- Accommodation: Pupils constrict when focusing on near objects and dilate when focusing on distant objects.
Signs of Possible Abuse
- Signs: Bruises, especially on upper arms and thighs (hidden), bite marks, deformities that don't match the injury, belt marks, burns.
Snellen Chart
- Purpose: Determines if a patient has myopia (impaired far vision). Tests for visual acuity.
- Procedure: Remove reading glasses. Patient reads letters on the chart from 20 feet away.
- Expected finding: 20/20 vision.
- Example: 20/40 vision means the patient can see at 20 feet what a person with normal vision can see at 40 feet.
- First number: Distance the patient stands from the chart.
- Second number: Distance a person with normal vision can see the letters.
Rosenbaum Eye Chart
- Purpose: Determines if patient has presbyopia (impaired near vision).
- Procedure: Patient holds the chart 14 inches away from their face.
Ishihara Chart
- Purpose: Tests for color vision deficits.
Tympanic Temperature and Otoscopic Examination
- Pull the pinna up and back for an adult, down and back for a child.
- Otoscope is the necessary supply.
- Expected tympanic membrane appearance: pearly gray, translucent.
- Unexpected tympanic membrane findings: redness, inflammation, drainage, perforations.
- Conductive hearing loss can occur with excessive earwax (cerumen).
Clubbing of Fingernails
- Appearance: Enlarged, curved downward.
- Indication: Chronic hypoxia, indicative of conditions like cystic fibrosis, heart failure, pulmonary disease, and COPD.
- Expected nail findings: 160 degrees, convex, rounded, pinkish.
- Normal angle of nails: 160 degrees, characterized as convex.
Melanoma
- ABCDE: Asymmetry, Border irregular, Color variations/changing, Diameter greater than 6 mm, Evolving (in color and size).
- Seek dermatologist consultation if any of these characteristics are present.
- Prevention: Annual checkups, protective clothing, sunscreen, limited sun exposure, heightened awareness of sunburns.
- Risk factors: Caucasian ethnicity, family history, UV exposure, certain occupations.
Wound Assessment
- Signs of infection: Inflammation, redness, elevated white blood cell count, purulent drainage, pain, fever.
- Signs of wound healing: Scabbing, signs of adhesion, dryness, itching.
- Absence of erythema, edema, decreasing WBC count, and reduced pain are also indicative of healing.
The Older Adult and the Integumentary/HEENT System
- Expected findings: Loss of subcutaneous fat, decreased moisture and elasticity, prominent facial bones, difficulty hearing high-frequency sounds.
- Expected skin findings: Decreased vascularity, reduced sweat gland function, thinning hair/hair loss, decreased sense of taste, decreased vision, senile lentigines (liver spots).
- Unexpected skin findings: Redness of lower extremities, bruises, edema, lesions, hematoma, scales, pressure ulcers.
- Unexpected HEENT findings: Difficulty hearing high-frequency sounds, decreased sense of taste, decreased vision.
Lymph Node Examination
- Palpation technique: Use pads of index and middle fingers in a gentle circular motion with light pressure.
- Expected findings: Non-palpable, non-tender.
- Unexpected findings: Palpable lymph nodes should be movable, non-palpable lymph nodes should be non-tender.
- Thyroid: Feel for the thyroid during swallowing (up/down), should be non-tender, and smooth.
Hearing Loss
- Assessment questions: Do you wear hearing aids? Can you hear me? Recent change in hearing? History of ear infections?
- Conductive hearing loss: Excessive cerumen build-up, occupational noise exposure, headphone use, trauma, history of middle ear infections, q-tip usage, sinus infections.
Cranial Nerves
- Olfactory Nerve (I): Smell. Test by closing one eye and identifying a familiar smell.
- Optic Nerve (II): Visual acuity.
- Oculomotor Nerve (III): Eye movement, raising eyelid. Test using the "8" or "H" test.
- Trochlear Nerve (IV): Downward/inner eye movement. Test using the "8" or "H" test.
- Trigeminal Nerve (V): Facial sensation, biting, chewing. Test by assessing sensation on the face, and by observing tongue movement.
- Abducens Nerve (VI): Lateral eye movement. Test using the "8" or "H" test.
- Facial Nerve (VII): Facial expressions, taste.
- Vestibulocochlear Nerve (VIII): Balance and hearing. Test with a whisper test.
- Glossopharyngeal Nerve (IX): Gag reflex, swallowing, taste.
- Vagus Nerve (X): Gag reflex, sensation of pharynx and larynx.
- Accessory Nerve (XI): Shoulder and neck movement. Test by having the patient shrug their shoulders and turn their head from side to side.
- Hypoglossal Nerve (XII): Tongue movement and speech.
Weber Test
- Procedure: Tuning fork placed on the top of the head or base. Tests for bilateral hearing, specifically for conductive hearing loss.
- Expected findings: Hearing on both sides.
- Unexpected findings: Hearing on one side or not at all.
Integumentary Signs of Dehydration
- Skin: Tenting, pale/white mucous membranes, dry and chapped lips.
- Locations to check: Back of hand, clavicle.
Bony Prominences and Prevention of Pressure Ulcers
- Locations: Ankles, knees, shoulders, back of head, elbows.
- Pressure ulcer preventative measures: Frequent repositioning (every 2 hours), moisture reduction (changing linens, barrier creams), assistive devices to reduce pressure, elevation of heels with pillows.
- At-risk individuals: Elderly, unconscious individuals, those with chronic health issues or infections.
Braden Scale
- Categories: Sensory perception, moisture, activity, mobility, nutrition, friction/shear.
- Score interpretation: Higher scores (80/discharge) indicate lower risk, while lower scores (younger/bed ridden) indicate higher risk for skin breakdown.
Liver Failure
- Expected findings: Jaundice (yellowing of eyes, skin, and mucous membranes), including the palate.
PERRLA
- Assessment: Pupils are equal in size, round, reactive to light, and accomodate.
- Consensual constriction: Both pupils constrict when light is shined into one eye.
- Accommodation: Pupils constrict when focusing on near objects, and dilate when focusing on far objects.
Signs of Possible Abuse
- Skin: Bruises, especially on upper arms and thighs, bite marks, injuries that don't match the explanation, belt marks, burns.
Snellen Chart
- Purpose: To determine if a client has myopia (impaired far vision), visual acuity.
- Expected findings: 20/20 vision.
- Interpretation: The top number represents the distance the patient is standing from the chart, while the bottom number indicates the distance a person with normal visual acuity can see the same line.
- For example: 20/40 means the patient needs to be 20 feet away from the chart to read a line that a person with normal vision can read at 40 feet away.
Rosenbaum Eye Chart
- Purpose: To determine if a client has presbyopia (impaired near vision).
- Procedure: Hold the chart 14 inches away from the client.
Ishihara
- Purpose: To test for color vision.
Foot Care for Diabetics
- General guidelines: Use water-based lotions (not between toes), avoid flip flops, file nails straight, daily foot checks, no soaking, ensure dryness between toes, wear closed-toed shoes.
Herpes Zoster (Shingles)
- Priority nursing diagnosis: Pain management.
- Expected rash: Along nerve tracks, vesicular lesions that are contagious when open or blistered.
Skin Functions
- Protection: First line of defense against the environment.
- Prevention: Prevents penetration of harmful substances.
- Perception: Sensory function.
- Temperature regulation: Maintains a stable body temperature.
- Identification: Personal identity.
- Communication: Nonverbal communication.
- Wound repair: Heals injuries.
- Absorption and excretion: Absorbs some substances and excretes others.
- Vitamin D synthesis: Converts vitamin D from sunlight.
- Calcium absorption: Necessary for calcium absorption from the intestines.
Staging of Pressure Ulcers
- Stage 1: Non-blanchable erythema, intact skin. Darker skin tones may display a blue or purple hue.
- Stage 2: Partial thickness skin breakdown involving the epidermis and dermis. Superficial, red-pink wound bed.
- Stage 3: Full thickness skin loss, damage to subcutaneous tissue. Deep, without exposed bone or muscle.
- Stage 4: Full tissue loss, necrosis, slough, black scabbing, tunneling or undermining.
- Unstageable: Unknown depth or injury, requires debridement to start healing.
- DTI (Deep Tissue Injury): Discoloration of intact skin, damage to underlying tissues.
Edema
- Scale: 1+ to 4+
- 1+ (Trace): 2 mm indentation, rapid skin return.
- 2+ (Mild): 4 mm indentation, 10-15 second skin return.
- 3+ (Moderate): 6 mm indentation, prolonged skin return.
- 4+ (Severe): 8 mm indentation, prolonged skin return.
Thyroid Gland
- Assessment: Hyperextend the client's neck and ask them to swallow.
- Expected findings: Smooth, non-tender, with normal swallowing.
- Unexpected findings: Thyroid enlargement, tenderness.
Temperature Assessment
- Technique: Use the pads of the fingers.
Drainage Characteristics
- Serous: Clear, watery drainage.
- Sanguineous: Pink-tinged drainage (bloody).
- Purulent: Thick, pus-like drainage with odor.
Skin Turgor
- Purpose: To assess for dehydration.
- Assessment: Pinch the skin on the clavicle (older adult), or the back of the hand (younger adult).
- Normal findings: The skin returns to its normal position quickly.
- Abnormal findings: Skin returns to its normal position slowly.
- Tenting: Indicates dehydration.
Primary Skin Lesions
- Examples: Nodules, pustules, atrophy, wheals, plaques, patches, tumors, vesicles, bullae, urticaria (hives).
Secondary Skin Lesions
- Develop from primary lesions.
- Examples: Keloids, crust, scales, fissures, erosions, scars, atrophic scars.
Sinus Palpation
- Technique: Use thumbs to palpate the frontal sinuses (press firmly upward just below the eyebrows).
Skin Assessment
- Inspection: Observe the color, temperature, hair distribution, lesions, moles, and signs of inflammation.
- Palpation: Check for general pigmentation, freckles, moles, birthmarks, widespread color changes, and moisture with fingertips.
- Auscultation/Percussion: Not typically performed.
Skin Color Changes
- Pallor (Pale): Loss of color.
- Erythema (Reddish): Reddish tone.
- Cyanosis (Blue): Bluish discoloration.
- Jaundice (Yellow): Yellow to yellow-orange discoloration.
Capillary Refill
- Procedure: Press on the fingernail bed and observe the return of blood flow.
- Expected findings: Return of circulation within 1-2 seconds.
- Sluggish capillary refill: Return of circulation takes longer than 1-2 seconds.
Neck Assessment
- Expected findings: Normal movement: forward-backward, side-to-side. Trachea midline.
- Unexpected findings: Tracheal shift, limited neck movement.
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Description
Test your knowledge on nursing interventions, assessment techniques, and common complications in patient care. This quiz covers topics such as the use of cold therapy, abnormal moles, dehydration, respiratory patterns, and COPD management. Perfect for nursing students and healthcare professionals looking to refresh their understanding of critical nursing principles.
