Skin Assessment Review PDF

**Skin Assessment** - **Order of Assessment:** 1. Examine upper extremities with client sitting or recumbent. 2. Remove stockings/socks and drape to expose entire lower extremity. 3. Ensure adequate natural lighting and comfortable temperature. 4. Ask client to rem...

**Skin Assessment** - **Order of Assessment:** 1. Examine upper extremities with client sitting or recumbent. 2. Remove stockings/socks and drape to expose entire lower extremity. 3. Ensure adequate natural lighting and comfortable temperature. 4. Ask client to remove wig as necessary. 5. Assess hair, skin, and nail color for uniformity. 6. Note cleanliness and odors. 7. Palpate skin temperature with dorsal (back of the hand). 8. Assess skin turgor by lifting and releasing a fold of skin on the forearm or sternum (or abdomen in infants). - **Abnormal Findings:** 1. **Pallor:** Loss of color (grey in black skin, pale in white skin, yellow/brown in brown skin). Indicates anemia, shock, or lack of blood flow. Check face, conjunctiva, nailbeds, palms, lips, and buccal mucosa. 2. **Cyanosis:** Bluish in light skin, grey in dark skin, yellow in brown skin. Indicates hypoxia or impaired venous return. Check nailbeds, lips, mucosa, skin, and palms. 3. **Jaundice:** Yellow to orange discoloration. Indicates liver dysfunction or red blood cell destruction. Check skin, eyes, and mucosa. 4. **Erythema:** Redness. Indicates inflammation, localized vasodilation, substance use, sun exposure, rash, or hyperthermia. Check face, trunk, extremities, areas of trauma or pressure injury. - **Skin Lesions:** 1. **Primary Lesions (arise from healthy skin tissue):** - **Macule:** Nonpalpable skin color change, \< 1 cm (e.g., freckle, petechiae). - **Papule:** Palpable, circumscribed, solid elevation of skin, \< 1 cm (e.g., elevated nevus/mole). - **Nodule:** Palpable, circumscribed, deep, firm, 1-2 cm (e.g., wart). - **Vesicle:** Serous fluid-filled, \< 1 cm (e.g., blister, herpes simplex, Varicella). - **Pustule:** Pus-filled, varies in size (e.g., acne). - **Tumor:** Solid mass, deep, \> 1-2 cm (e.g., epithelioma). - **Weal:** Palpable, irregular borders, edematous (e.g., insect bite). - **Atrophy:** Thinning of skin, loss of normal skin furrows, skin is shiny and translucent (e.g., arterial insufficiency). 2. **Secondary Lesions (result from changes in primary lesions):** - **Erosion:** Lost epidermis, moist surface, no bleeding (e.g., ruptured vesicle). - **Crust:** Dried blood, serum, or pus (e.g., scab). - **Scale:** Flakes of skin that exfoliate (e.g., dandruff, psoriasis, eczema). - **Fissure:** Linear crack (e.g., tinea pedis). - **Ulcer:** Loss of epidermis and dermis with possible bleeding, scarring (e.g., venous stasis ulcer, pressure ulcer). 3. **Check Lesions for:** - **A - Asymmetry of shape** - **B - Border irregularity** - **C - Color variation within one lesion** - **D - Diameter \> 6 mm** - **E - Evolving, change in color, elevation, shape, itching, crusting, bleeding.** - **Pressure Injury Stages:** 1. **Stage 1:** Nonblanchable erythema of intact skin, tissue is swollen, redness, warmer or cooler to the touch. 2. **Stage 2:** Partial thickness skin loss with exposed dermis, may appear as intact or ruptured blister. 3. **Stage 3:** Full thickness skin loss, visible adipose tissue, no exposed muscle or bone. 4. **Stage 4:** Full thickness skin and tissue loss, tunneling, cartilage, bone, muscle ligaments, and tendons exposed. - **Edema:** 1. Accumulation of fluid in tissues, often from direct trauma or impaired venous return. 2. Evaluate pitting edema by compressing skin for at least 5 seconds over a bony prominence (e.g., medial malleolus, dorsum of foot, over shin), then assess depth: - **1+ = trace, 2mm, rapid skin response** - **2+ = mild, 4mm, 10-15 second skin response** - **3+ = moderate, 6mm, prolonged skin response** - **4+ = severe, 8 mm, prolonged skin response** - **Skin Cancer Risks:** 1. Exposure to UV light 2. Chronic skin inflammation, burns, or scars 3. Family history 4. Presense of large or many small moles 5. Fair complexion 6. Immunosuppression therapy - **Vascular Lesions (result from aging changes or blood vessel damage):** 1. **Spider angioma:** Red center with radiating red legs. 2. **Cherry angioma:** Red, round, raised. 3. **Spider vein:** Bluish, spider-shaped. 4. **Petechiae:** Deep reddish-purple flat. 5. **Ecchymosis:** Purple fading to green/yellow. 6. **Hematoma:** Raised ecchymosis. **Respiratory** - **Percussion:** - Compare sounds from side to side. - **Dullness:** in fluid or solid tissue, indicates pneumonia or tumor. - **Hyperresonance:** in the presence of air, indicates pneumothorax or emphysema. - **Auscultation:** - **Expected Sounds:** - **Bronchial:** loud high pitched, expiration longer than inspiration over the trachea. - **Bronchovesicular:** medium pitch, equal inspiration and expiration. - **Vesicular:** soft low pitched, inspiration 3x longer than expiration. - **Adventitious Lung Sounds:** - **Crackles or Rales:** fine course bubbly sounds. - **Wheezes:** high pitched whistling. - **Rhonchi:** coarse, loud, low-pitched rumbling. - **Pleural friction rub:** dry, grating or rubbing sounds. - **Absence of breath sounds:** from collapsed or surgically removed lobes. - **Respiration Patterns:** - **Normal:** 12-20 breaths per minute. - **Tachypnea:** 24+ breaths per minute, shallow. - **Bradypnea:** \< 10 breaths per minute, regular. - **Hyperventilation:** increased rate, depth. - **Kussmaul:** rapid, deep, labored. - **Hypoventilation:** decreased rate, decreased depth, irregular pattern. - **Cheyne-strokes:** regular pattern of alternating deep rapid breathing followed by periods of apnea (END of LIFE). - **Biot respirations:** irregular pattern, varying depth and rate followed by periods of apnea. - **Asthma:** - Chronic disorder of the airways resulting in intermittent and reversible airflow obstruction of the bronchioles. - Obstruction occurs by either inflammation or airway hyperresponsiveness. - Manifestations: mucosal edema, bronchoconstriction, excessive mucus production. - Expected findings: dyspnea, chest tightness, anxiety, stress. - Physical assessment findings: coughing, wheezing, mucus production, use of accessory muscles, prolonged exhalation, low SPO2. - Treatment: Albuterol - beta 2 adrenergic agonist. - **COPD (Chronic Obstructive Pulmonary Disease):** - Encompasses 2 diseases: emphysema and chronic bronchitis. - Irreversible. - Expected findings: chronic dyspnea, tachypnea, lower Spo2, hypercarbia. - Exacerbation: medical emergency. - Physical assessment findings: Clubbing of the fingers/toes, Barrel Chest. **Cardiovascular** - **Heart Anatomy:** - The right side of the heart pumps blood to the lungs for gas exchange (pulmonary circulation) but removing CO2 and replenishing the oxygen supply. - The left side of the heart pumps blood to the rest of the body. - **Heart Valves:** - **Atrioventricular Valves (located at the entrance of the ventricles):** - **Tricuspid:** Right atrium and right ventricle. - **Bicuspid:** Left atrium and right ventricle. - When the ventricles contract, the AV valves shut, preventing the regurgitation of blood into the atria (no backflow). - **Semilunar Valves (located at each exit of each ventricle at the beginning of the great vessels):** - **Pulmonic:** Right ventricle and pulmonary vein. - **Aortic:** Left Ventricle and Aorta. - These valves open during ventricular contraction and close from the pressure of blood when the ventricles relax. - **Anatomical Positions for Heart Sounds:** - **Aortic Area:** 2nd ICS at the RIGHT sternal border base of the heart. - **Pulmonic Area:** 2nd ICS at the LEFT sternal border- the base of the heart. - **ERB Point:** 3rd ICS at the left sternal border. - **Mitral (apical):** Left midclavicular line at the 5th ICS. - **Tricuspid Area:** Just left of the sternum at the 4th ICS. - **Heart Sounds:** - **S1 (Lub):** closure of mitral and tricuspid valves signals the beginning of ventricular systole (contraction). - **S2 (Dub):** closure of the aortic and pulmonic valves signals the beginning of ventricular diastole (relaxation). - **S3:** Ventricular Gallup indicates rapid ventricular filling heard after S2 (KENTUCKY). - Expected finding in children, young adults (bell of stethoscope). - **S4:** strong atrial contraction. Heard before S1 (TENESSEE). - Expected finding in elderly and adults (bell of stethoscope). - **Murmurs (turbulent blood flow):** - Not normal, more audible when blood volume in the heart is increased, bell of the stethoscope, blowing or swishing sound. - **Systolic murmur:** just after S1. - **Diastolic murmur:** just after S2. - **Thrills:** palpable vibration can accompany murmurs or cardiac malformation. - **Bruits:** blowing or swishing sounds that indicate obstructed peripheral blood flow, bell of the stethoscope. - **MI (Myocardial Infarction - Heart Attack):** - Heavy chest pressure with exertion across chest radiating to shoulders, jaw, neck, and abdomen, lasts couple hours not relieved by rest. Nausea and vomiting, sweating. - Risk factors: Cholesterol, Stress, Cocaine use/methamphetamine, Male or post-menopause Hypertension, Excessive alcohol, Obesity. - Health promotion: Maintain exercise, have cholesterol and blood pressure checked regularly, and consume a diet low in saturated fats and sodium to promote smoking cessation. - Expected findings: Anxiety, feeling of impending doom, Chest pain, nausea, dizziness, SOB. - **Heart Failure:** - **Left side:** left is lungs. - Dyspnea, orthopnea (SOB while laying down). Nocturnal dyspnea. - Fatigue. - Displaced apical pulse (hypertrophy). - S3 sound: Gallup. **Cardiovascular System** - **Heart Sounds and Murmurs** - **Murmurs:** Turbulent blood flow, more audible when blood volume in the heart is increased, detected with the bell of the stethoscope, produces a blowing or swishing sound - **Systolic murmur:** Occurs just after S1 - **Diastolic murmur:** Occurs just after S2 - **Thrills:** Palpable vibrations that can accompany murmurs or cardiac malformations - **Bruits:** Blowing or swishing sounds indicating obstructed peripheral blood flow, detected with the bell of the stethoscope - **Blood Flow and Circulation** - **Right side of the heart:** Pumps blood to the lungs for gas exchange (pulmonary circulation), removing CO2 and replenishing oxygen supply - **Left side of the heart:** Pumps blood to the rest of the body - **Anatomical Positions for Heart Sounds** - **Aortic Area:** 2nd ICS at the RIGHT sternal border, at the base of the heart - **Pulmonic Area:** 2nd ICS at the LEFT sternal border, at the base of the heart - **ERB Point:** 3rd ICS at the left sternal border - **Mitral (apical):** Left midclavicular line at the 5th ICS - **Tricuspid Area:** Just left of the sternum at the 4th ICS - **Myocardial Infarction (MI)** - **Characteristics:** - **C:** Heavy, tight pressing - **O:** Discomfort with or without exertion - **L:** Across chest and may radiate to shoulders, jaws, neck, or upper abdomen - **D:** Lasts 20 min to hours - **S:** Often moderate to severe pain - **P:** Rest does not relieve - **A:** May occur with nausea, vomiting, weakness, and sweating - **Risk factors:** - Cholesterol - Stress - Cocaine use/methamphetamine - Male or post-menopause - Hypertension - Excessive alcohol - Obesity - **Health promotion:** - Maintain exercise - Have cholesterol and blood pressure checked regularly - Consume a diet low in saturated fats and sodium - Promote smoking cessation - **Expected findings:** - Anxiety - Feeling of impending doom - Chest pain - Nausea - Dizziness - SOB - **Heart Failure** - **Left side:** Affects the lungs - Manifestations: - Dyspnea - Orthopnea (SOB while laying down) - Nocturnal dyspnea - Fatigue - Displaced apical pulse (hypertrophy) - S3 sound (Gallup) - Pulmonary congestion (dyspnea, cough, bibasilar crackles) - Frothy or blood-tinged sputum - Altered mental status - Nocturia - Manifestation of organ failure (oliguria) - **Right side:** Affects the rest of the body - Manifestations: - Jugular vein distention - Ascending dependent edema (legs, ankles, sacrum) - Abdominal distension - Fatigue - Weakness - Nausea and anorexia - Polyuria at rest (nocturnal) - Liver enlargement - Weight gain - **Heart Chambers and Valves** - **Atrioventricular Valves:** Located at the entrance of the ventricles - **Tricuspid** - **Bicuspid** - Open AV valves allow blood flow from the atria into the ventricles - When ventricles contract, the AV valves shut preventing regurgitation of blood into the atria (no back flow) - **Semilunar valves are located at each exit of each ventricle at the beginning of the great vessels** - **Pulmonic** - **Aortic** - These valves open during ventricular contraction and close from the pressure of blood when the ventricles relax - **Cardiac Output** - Defined as the amount of blood pumped by the ventricles during a given period of time (usually 1 min) - Determined by the stroke volume (SV) multiplied by the heart rate (HR) - Normal: 5-6 L/min - SV X HR = CO - **Heart Disease** - **Valvular heart disease expected findings:** - Manifestations do not show up until late - Murmur is heard with turbulent blood flow - Left side damage causes increased pulmonary artery pressure, left ventricular hypertrophy, and decreased cardiac output, resulting in orthopnea, PND, and fatigue **Musculoskeletal System** - **Abnormal Curvatures of the Spine** - **Kyphosis:** Exaggerated curvature of the thoracic spine (older adults) - **Lordosis:** Exaggerated curvature of the lumbar spine (toddler years and pregnancy) - **Scoliosis:** Exaggerated lateral curve - **Osteoarthritis** - Characterized by progressive deterioration of the articulation cartlidge - Non-inflammatory (unless localized) - Non-systemic disease - Manifestations: - Kyphosis - Gallium has been studied as a possible treatment - Joint pain and stiffness - Heberden\'s nodes enlarged - Bouchard nodes inflamed and painful - **Expected Changes with Aging** - Reduced muscle mass - Declines in speed, strength, resistance to fatigue, reaction time, coordination - Decalcification of bones, leading to loss of bone mass and height, increasing risk for osteoporosis - Degenerative alterations in joints - Limited ROM - Thinning intervertebral discs, kyphosis (with height loss), wider stance altering posture - **Musculoskeletal Diagnostic Procedures** - **Gallium (CT) and Thallium Scans (MRI)** - More sensitive to detecting bone problems than a bone scan - The radioisotope migrates to tissues of the brain, liver and breast and helps detect disease of these organs - Client receives the radionuclide injection 4-6hrs before scanning - Scan takes 30-60min, can require sedation, repeat scans occurs at 24, 28, and 72 hr - **Examination of the Musculoskeletal System** - Includes assessing both its structure and function - Assessment involves examining each joint, muscle and the surrounding tissues bilaterally and looking for symmetry - Techniques: Inspection, palpation - **Skeletal Muscle Movements** - **Abduction:** Away from midline - **Adduction:** Toward the midline - **Circumduction:** Circular motion - **Inversion:** Turning toward the midline - **Eversion:** Turning away from the midline - **Extension:** Increases the angle between two adjacent bones - **Hyperextension:** Beyond its normal extended position - **Flexion:** Decreases the angle between two adjacent bones - **Dorsiflexion:** Flexing the foot and toes upward - **Plantarflexion:** Bending the foot and toes downward - **Pronation:** Front surface faces down - **Supination:** Ventral surface faces up - **Protraction:** Moving forward - **Retraction:** Moving backward - **Internal rotation:** Rotating joint inward - **External rotation:** Rotating joint outward