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• Week 5 In Class PPT covers chapters 14, 22, and 20.
• Chapter 14 covers skin, hair, and nails.
• Chapter 22 covers peripheral vascular and lymphatic systems.
• Chapter 20 covers the breast and lymphatic system.

Skin, Hair, and Nail Assessment: Subjective Data

• Subjective data collected about the skin, hair, and nails include present health concerns, personal health history, family history, and lifestyle and health practices.

Skin, Hair, and Nail Assessment: Objective Data

• Techniques used to assess the skin include inspection and palpation.
• Inspection includes assessments of color, odor, integrity (intactness), lesions, hair distribution, scalp and hair on the head, nail color, and shape.
• Palpation includes assessments of texture and thickness (skin, hair, and nails), moisture, temperature, mobility and turgor, and edema.

Braden Scale

• The Braden Scale predicts the risk of pressure sores.
• The six components of the Braden Scale are sensory perception, moisture, activity, mobility, nutrition, friction, and shear.
• Scoring is as follows: No risk (19-23), Mild risk (15-18), Moderate risk (13-14), High risk (10-12), Severe risk (</=9).

Pressure Ulcers

• Stage I: Intact skin with non-blanchable redness of a localized area.
• Stage II: Partial thickness skin loss with a shallow open ulcer, red-pink wound bed, without slough. It can also manifest as an intact or open blister that is shiny, dry, and shallow, without slough or bruising.
• Stage III: Full thickness tissue loss. Slough may be present and there may be tunneling. Bone or tendon is not visible.
• Stage IV: Full thickness tissue loss with bone, tendon, or muscle exposed. Slough is present and there is often tunneling.
• To prevent pressure ulcers: practice bathing/hygiene, use moisturizers, avoid vigorous massage, provide nutrition supplements, provide repositioning, use pressure mattresses, and lifting devices.

MRSA

• MRSA (Methicillin-resistant Staphylococcus aureus) is an infection resistant to antibiotics, and impaired skin integrity puts patients at risk.
• To prevent the spread: keep wounds covered, do not share personal items, avoid unsanitary or unsafe nail care practices, complete antibiotic treatment, use universal precautions, and wash hands.

Skin Cancer

• Teach patients to do a self-exam using the ABCDE method: A for asymmetry, B for irregular borders, C for color variations, D for diameter exceeding greater than 1/4 inch or 6 mm, and E for evolution (changes over time).
• Risk factors include sun exposure/tanning, family history, moles, fair skin that burns or freckles easily, and age.
• Patient teaching includes reducing sun exposure, using sunscreen (SPF 15 or higher), wearing sunglasses and a hat, avoiding sunburns, performing self-examinations, and ensuring adequate Vitamin B3.
• Collaboration with a physician, primary care provider, dermatologist, podiatrist, or wound care nurse may be needed for skin findings or anomalies.
• Asians and Native Americans have fewer apocrine glands (less sweat and body odor).
• Fair-skinned people are at the highest risk for skin cancers, dark-skinned people tend to be diagnosed later and have a poorer prognosis.
• Dermatologic diseases can affect the quality of life in many cultures, especially in females.
• Erythema in the dark-skinned client may be difficult to see with affected skin feeling swollen and warmer than the surrounding skin.

Aging Considerations

• Changes in the skin include decreased perspiration and sebum production (dryer skin). Hygiene practices may be more difficult for older adults
• The skin becomes pale, and skin lesions associated with aging may appear.
• Skin loses turgor due to decreased elasticity.
• The hair becomes coarser, drier, and thinner with slower growth.
• Nails may become thicker, yellow, and brittle.

Peripheral Vascular System: Subjective Data

• Subjective data collected about the peripheral vascular system includes present health concerns, personal health history, family history, and lifestyle and health practices.

Peripheral Vascular System: Objective Data

• Assessment helps identify or differentiate arterial insufficiency, venous insufficiency, and lymphatic involvement.
• Techniques used to assess the PV system include inspection and palpation.

Arterial Insufficiency vs. Venous Insufficiency vs. Lymphedema

• Arterial Insufficiency: Pain can be intermittent, pulses are diminished, skin is pallor, dry and shiny, edema is minimal (unless extremity kept in dependent position), and ulcers are painful and deep with clean edges. Claudication and absent or loss of hair, skin cool to cold, thick or rigid nails, pressure areas (black/gangrene).
• Venous Insufficiency: Aching, cramping, pulses are present but difficult to palpate, pigmentation changes (reddish-blue or brown color), skin is thick and tough, edema may be present, and ulcers may have irregular edges and be bleeding.
• Lymphedema: Aching, heaviness/tightness, no changes in pulse, smooth shiny tightened skin, swelling may be unilateral, no ulcers.

Risk Assessment: Peripheral Artery Disease (PAD)

• Risk factors for PAD include smoking, diabetes, obesity, hypertension, hyperlipidemia, increased age, family history, and African American descent.

Breast and Lymphatics: Subjective Data

• Subjective data collected includes history of present health concerns, personal health history, family history, and lifestyle and health practices.

Breast and Lymphatics: Objective Data

• Techniques used to assess the breast and lymphatics include inspection and palpation, including the axillary area.
• Inspection involves size, symmetry, color, texture, venous patterns, areolas, nipples, retraction, and dimpling.
• Palaption involves texture, tenderness, temperature, discharge, masses.

Head & Neck: Subjective Data

• Subjective data relates to history of present concern, family history, head or neck pain, limited range of motion, lumps or lesions, cough or difficulty swallowing, dizziness/lightheadedness, and lifestyle and health practices (smoking/alcohol use, recreational drugs, helmet use).

Head & Neck: Objective Data

• Includes inspection (head size, shape, symmetry, involuntary movements, face, neck movement and structure, range of motion, color changes) and palpation (head, temporal artery, temporomandibular joint, cervical vertebrae, trachea, thyroid gland, and lymph nodes).
• Auscultation: Listen to thyroid for enlargement.

Considerations for Older Adults

• Arthritis can decrease range of motion and cause pain.
• Osteoporosis can affect posture and neck.
• Wrinkles exist, and the mouth may be drawn inward with the lower face shrinking.
• Pulsation and strength of the temporal artery decreases.
• Cervical curvature increases due to kyphosis.
• Decreased flexion, extension, lateral bending, and rotation of the neck may occur.

Conditions of Head and Neck

• Traumatic Brain Injury (TBI): Risk is highest in newborns to 4-year-olds, teenagers, and adults over 65, and is associated with transportation, violence, falls, and alcohol ingestion.
• Prevention: Use seatbelts/safety seats, don't drive under the influence, wear helmets, and decrease fall risks.
• Headaches: Types include sinus, cluster, tension, migraine, and tumor-related.
• Cushing syndrome: Moon face, reddened cheeks, increased facial hair.
• Thyroid conditions: Hypothyroidism (dry, coarse hair; periorbital edema; puffy dull face with dry skin, fatigue, weight gain) and Hyperthyroidism (hair loss, lid lag, thyroid enlargement, anxiety).
• Bell Palsy: Unilateral facial drooping.
• Parkinson's disease: Tremors, masked-like face, shuffling gait.
• Cerebrovascular accident (CVA, Stroke): Face droop, difficulty seeing or speaking, numbness, or weakness.

Eyes: Subjective Data

• Includes history of present concern, changes in vision (spots/floaters, blind spots, halos/rings, trouble seeing at night, double vision, eye pain/itching, redness/swelling, watering/tearing, discharge), past health history, family history (eye problems/vision loss), and lifestyle and health practices (exposure to conditions/substances, use of safety glasses/sunglasses, vision loss affecting ability to work/care for self, visual aids, diet/nutrition, smoking).

Eyes: Objective Data

• Includes visual acuity tests for far and near vision, visual field tests (confrontation test), cardinal fields of gaze test, and extraocular muscle function.
• Assessment include the eyelids, eyelashes, redness, swelling, discharge, lesions, position/alignment of eyeball, conjunctiva and sclera, cornea and lens, pupils, pupil reaction, and accommodation.

Disorders of the Eye

• Glaucoma: Patchy, blind spots in peripheral or central vision, headache, eye pain, blurred vision, halos, redness. Risk factors include high eye pressure, family history, >40 for African Americans, >60 for other general population, thin cornea, diabetes, high blood pressure, eye injury or surgery.
• Macular Degeneration: Blind spots and blurred or distorted vision. Risk factors include old age, smoking, family history, gender, obesity, race, light eye color, sun exposure, hypertension, and cardiovascular disease.
• Cataracts: Clouding of lens, poor night vision, halos, douible vision. Risk factors include increasing age, diabetes, exposure to sunlight, smoking, obesity, high blood pressure, and alcohol.

Ears: Subjective Data

• Includes history of present concern, recent changes in hearing, drainage, pain, ringing or crackling, dizziness or unbalance, personal health history (ear problems, trauma/infections/earaches, treatments), family history (hearing loss), and lifestyle and health practices (exposure to loud noises, use of protection, swimming).

Ears: Objective Data

• Includes inspection (auricle, tragus, lobule, otoscopic exam of auditory canal and tympanic membrane) and palpation (auricle and mastoid process).
• Hearing tests: Whisper test and Weber test.
• Four tests evaluate hearing/conduction of sound waves: Whisper test, Weber test, Rinne test, and Romberg test.

Hearing Loss

• Risk factors include aging, heredity, occupational/recreational noises, medications, and illness.
• Patient education includes hearing protectors, hearing exams, immunizing children, avoiding ototoxic medications and instruments to remove wax, treating ear infections, and avoiding sound exposure.

Mouth, Throat, Nose, & Sinuses: Subjective Data

• Includes history of present health concern (sores/lesions, redness/swelling, bleeding, pain, nose bleeds, nasal drainage, breathing problems/stuffiness, change in smell or taste, difficulty swallowing, sore throat, hoarseness), personal health history (surgeries, sinus infections, allergies, medications), family history (cancers of mouth/nose/throat), and lifestyle and health practices (smoking/alcohol, teeth grinding, hygiene, dental exams/braces/dentures, sun exposure, dietary intake).

Mouth, Throat, Nose, & Sinuses: Objective Data

• Assessment Techniques:
  • Inspection: Lips, teeth, gums, buccal mucosa, ventral/sides of tongue, uvula, tonsils, external nose, internal nose.
  • Palpation: External nose, sinuses, patency of the nose.

Oropharyngeal Cancer

• Risk factors include tobacco/alcohol use, HPV, sunlight exposure, age over 45 fair skin, poor oral hygiene/diet, weak immune system.
• Education should focus on avoiding tobacco/excessive alcohol, avoiding HPV infection/sun exposure, a healthy diet, good oral hygiene, and well-fitting dentures.

Nutrition Assessment

• Essential Nutrients: Includes carbohydrates, proteins, fats, vitamins, minerals, and water.
• Healthy Diet: Consists of 45-65% carbohydrates (75% being complex).
• Undernutrition/Malnutrition: Can exacerbate or facilitate diseases.
• Overnutrition: Increased caloric consumption, especially high in fats and sugar, with decreased energy expenditure, can lead to obesity.
• Metabolic Demands: Vary based on developmental level, lifestyle, and energy demands.
• Vulnerable groups for under-nutrition: infants/children, pregnant women, recent immigrants, low income, hospitalized and aging individuals.
• Common Illnesses/Disorders Associated with Altered Nutrition: Lower socioeconomic status, lifestyle of long work hours (fast food/vending machine meals), poor food choices, chronic dieting, chronic diseases, dental issues, and disorders with self-limited/refused food.
• Provide insight into the patient's overall health, baseline data for evaluation and to identify risk factors, dietary deficits, those malnourished or at risk; to provide data to facilitate individualized plan of care. Should guide heatlh promotion and disease prevention.

Nutritional screening

• 24-hour food recall, diet, personal/family health history, and lifestyle/health practices.
• Eating patterns: "Normal" & Changes in appetite, taste, smell, chewing, swallowing, activities of daily living to diet.

Body Assessments During nutritional assessment

• Body build (ectomorph, mesomorph, endomorph), height/weight, BMI, waist/mid-arm circumference, triceps skinfold thickness/mid-arm muscle circumference.
• Weight: Weight gains or losses of 6-10 lb (intake/output, skin turgor, pitting edema, skin/moisture, venous filling, lung sounds, tongue forrows etc).

Dehydration and weight changes

• Weight gains of 6-10 lb in a week, pitting edema, visible neck veins, cracking lung sounds, elevated pulse rate and blood pressure are potential findings.
• Weight losses of 6-10 lb in 1 week, tenting, filling or empyting of venous filling more than 6-10 seconds, flat veins in supine client, dry tongue, sunken eyes, blood pressure decreased with elevated pulse rate, radial pulse rate +1.

Laboratory Tests

• Tests can identify undernutrition/malnutrition status table: Hemoglobin(Males: 13 – 18 g/dL and Female: 13 – 16 g/dL
• Total protein level 6-8g/dL and Hematocrit Females: 36% - 48% and Males: 40% - 52%
• Fasting Blood Sugar 65-99 mg/dL with focus for increase need for calories and iron/folate/zinc

Changing physical abilities

• Polypharmacy and changing physical abilities (Decreased physical health & organ function, loss of teeth, loss of lean body mass, change in taste, smell ↓ functional ability)
• 10% weight loss in after birth - regain by 7th to 10th day Breastfeeding recommenced for the first years.

Patient scoring notes:

• Braden Scale: Sensory perception, moisture, activity, mobility, nutrition, friction and shear (scores 1-4 or friction with 1-3) = higher score for better care percent score=23 (mild risk 15-18, moderate risk 13-14, high risk 10-12, severe risk < 9)
• The three types of skin cancer are melanoma, basal cell carcinoma, squamous cell

all people should do a routine self-exam on themselves and children looking for skin cancer, risk factors includes -sun exposure/tanning, family history, moles and easy skin burn when freckles.

• Patient education can decrease by sun exposure and using spf 30 or higher also use heat and avoid sunburns after self-exams, dryer skin and skin looses turgor with aging (sagging or wrinkles) and nails may become tick etc.

Pressure injury assessment

• Stage 1 pressure ulcer: intact skin with non-blanchable redness of a localized area.
• Stage 2 pressure ulcer: partial thickness, shallow open ulcer with a red-pink wound be no slough.
• Stage 3 and 4 is total pressure ulcer.
• MRSA(infection resistant to many antibiotics, hospital or community acquired infection and impaired skin integrity. Patient education for MSRA keep using bandages/wound covered, do not have personal sanitary /nail care practice,s and precautions with hand hygiene.

The network of vessels includes

• Major sites skin on the body and major pulse/lymph notes including venous and aterial insufficiency
• Palpating pulses: 0 - absent, 1+ edema=mild , 2+ edema (regular), 3+ edema (looks swollen), 4+ edema(extremely swollen. Looked for upper/lower and femoral pulses and equal on both sides (TBI)- mild to severe

Raynauds disease and Head/Neck symptoms:

• Head /neck may be triggered with pressure (cold), and other issues
• Sinus and allergies
• Check for swelling/redness for eye
• Vision assess with near and far
• Hearing with webers/whisper or rines test
• All factors for hearing loss or illness and pt education.