Objectives PDF

Objectives Wednesday, January 29, 2025 4:10 PM 1. Document the assessment of the skin, hair, nails, head and neck using correct descriptive terminology. SKIN INSPECTION NORMAL FINDINGS ABNORMAL Inspect general...

Objectives Wednesday, January 29, 2025 4:10 PM 1. Document the assessment of the skin, hair, nails, head and neck using correct descriptive terminology. SKIN INSPECTION NORMAL FINDINGS ABNORMAL Inspect general skin coloration Evenly colored skin tones Pallor : loss of color No discolorations Cyanosis : blue skin, central: cardiopulmonary problem, peripheral : local from vasoconstriction Jaundice : yellow skin tones Acanthosis nigricans : velvety darkening of skin Note odors Slight to no odor of perspiration Strong odor or foul odor Disorder of sweat glands Poor hygiene practices Client education Assistance with ADL Color variation Sun tanned areas, freckles, vitiligo Rashes, darkened butterfly rash across bridge of Albinism : general loss of nose and cheeks pigmentation Lupus Erythema : redness and warmth Inflammation, allergic reactions, trauma Skin integrity Intact and no reddened areas Skin breakdown Pressure injuries Skin lesions Smooth without lesions Can indicate local or systemic problems Note ABCDE Stretch marks, healed scars, Primary : irritation or disease freckles, moles, birth marks Secondary : arise from primary Vascular : reddish blue are seen with bleeding, venous pressure, aging, liver disease, pregnancy Cancerous : primary or secondary and are classified Fungus Does not fluoresce Blue-green fluoresce indicates fungal infection Shine wood light on lesion PALPATION Assess texture Skin is smooth and even Rough, flaky, dry Hypothyroidism Assess thickness Normally thin, except for calluses Very thin If lesions are noted, palpate for size, Arterial insufficiency or steroid therapy mobility, consistency, and tenderness Infected lesions are tender to palpate OLDER ADULT CONSIDERATIONS Observe for drainage Nonmobile, fixed by be cancer Skin becomes pale due to decreased melanin production and decreased dermal vascularity Assess moisture Surfaces vary from moist to dry Increased moisture occur in fever or May feel dryer than younger clients because sebum production decreases with age depending on area assessed hyperthyroidism Loses turgor because of its decrease in elasticity and collagen fibers Decreased moisture occurs in dehydration or ○ Sagging, wrinkles skin hypothyroidism Nails may appear thickened, yellow and brittle from decreased circulation in the extremities Clammy skin Hair feels coarser and drier Shock or hypotension Hair is thinner and slower growth ○ From decrease in hair follicles Assess temperature Normally warm Cold Alopecia is seen in men Use dorsal surfaces of hands Shock or hypotension ○ From periphery of scalp and moves to the center Cool Older women may have terminal hair growth on the chin from hormonal changes Arterial disease Strength of pulsation of temporal artery may be decreased Very warm Facial wrinkles are prominent bc subq fat decreases with age Febrile state or hyperthyroidism Lower face may shrink and mouth may be drawn inward from resorption of mandibular bone Assess mobility and turgor Skin is mobile, with elasticity Decreased mobility Cervical curvature: kyphosis Pinch skin over clavicle Recoil is immediate Edema Fat may accumulate around cervical vertebrae (Women): dowagers hump ○ Mobility: how easily skin can be Decreased turgor Decreased flexion, extension, lateral bending, and rotation of neck from arthritis pinched Dehydration If thyroid is palpable, nodular may be from fibrotic changes that ○ Turgor: elasticity ○ More than 3 seconds: tenting Thyroid may be felt lower in the neck Detect edema Skin rebounds and does not Indention remain indented Peripheral vascular system problem HEAD AND FACE INSPECTION NORMAL FINDINGS ABNORMAL Inspect the head Head size can vary with ethnicity Microcephaly: abnormally small Head is symmetric, round, erect, midline Acromegaly: skull and facial bones are larger and Normocephalic NAILS thicker No lesions are visible Pagets disease: acorn shaped, enlarged skill bones INSPECTION NORMAL FINDINGS ABNORMAL Inspect for involuntary movement Head should be held still and upright Horizontal jerking Nail grooming and cleanliness Nails are clean and manicured Dirty, broken or jagged Neuro disorders Poor hygiene Aortic insufficiency Hobby or occupation Head tilted to one side Nail color and markings Pink tones should be seen Pale or cyanotic Unilateral vision, hearing deficiency, Longitudinal ridging is normal Hypoxia or anemia shortening of the sternomastoid muscle Splinter hemorrhages Palpate head Head is normally hard and smooth Lesions or lumps Trauma Recent trauma Beau lines Signs of cancer Acute illness and grow put Yellow discoloration Inspect the face Face is symmetric with round, oval, Asymmetry anterior to the earlobes occur with Seen in fungal infections Symmetry, features, movement, elongated, or square appearance parotid gland enlargement Psoriasis expressions, skin conditions No abnormal movements noted Tumor or abscess Nail pitting Drooping of one side: assess for Unusual or asymmetric orofacial movements Psoriasis signs of stroke Organic disease or neuro problem Drooping, weakness or paralysis on one side of Nail shape 160 degrees between nail base Early clubbing : 180 the face and skin Late clubbing : greater than 180 Stroke (CVA) Hypoxia Bell palsy Spoon nails: concave Mask like face, Iron deficiency anemia Parkinson disease PALPATION sunken face with depressed eyes and hollow cheeks Assess texture Nails are hard and immobile Thickened nails Cachexia (muscle wasting) Decreased circulation Pale, swollen face Onychomycosis Nephrotic syndrome Assess consistency Nails are smooth and firm Paronychia Palpate temporal artery Elastic and not tender Hard, thick, tender with inflammation Plate is firmly attached to nail Local infection Temporal arteritis bed Onycholysis Detachment of nail plate from Palpate TMJ No swelling, tenderness, crepitation with Limited ROM, swelling, tenderness, or crepitation nail bed movement TMJ syndrome Trauma - mouth opens and closes fully *assess hx of headaches* Lower jaw moves laterally 1-2cm in each Capillary refill Pink tone returns immediately Slow refill : greater than 2 seconds direction Press nail tip and watch the Resp or cardio disease color Hypoxia THE NECK INSPECTION NORMAL FINDINGS ABNORMAL Inspect the neck Neck is symmetric with head centered Swelling, enlarged masses Shine penlight from side of neck to and without bulging masses Enlarged thyroid highlight swelling Inflammation of lymph nodes Tumor SCALP AND HAIR Inspect movement of the neck Thyroid cartilage and cricoid move Asymmetric movement or generalized enlargement INSPECTION NORMAL FINDINGS ABNORMAL Swallow a sip of water upward symmetrically as the client of the thyroid gland Inspect general color and condition Natural hair color Nutritional deficiencies swallows Patchy gray hair Inspect the cervical vertebrae C7 is visible and palpable Prominence or swellings other than C7 Copper red hair Flex the neck (chin to chest) Severe protein malnutrition in African american Inspect ROM Movement is smooth and controlled Muscle spasms, inflammation, cervical arthritis may Turn head to right, left, touch ear to cause stiffness, rigidity, and limited mobility of the Palpate for cleanliness, dryness or oiliness, Scalp in clean and dry Excessive scaliness shoulder, chin to chest, chin to neck parasites and lesions Sparse dandruff Dermatitis ceiling Can affect daily functioning Wear gloves Hair is smooth and firm, Raised lesions *stiff neck, fever, HA, n/v, photophobia, confusion elastic Infection or tumor growth Meningitis, seek immediate care Dull, dry hair Hypothyroidism, malnutrition PALPATION Poor hygiene Palpate the trachea Trachea is midline pulled to the affected side Client education and large atelectasis, fibrosis, or pleural adhesion assistance with ADL Pushed to unaffected side Pustules with hair loss in patches Tumor, enlarged thyroid lob, pneumothorax, Tinea capitis aortic aneurysm Contagious fungal disease Folliculitis Palpate the thyroid gland Not palpable Enlargement Pustules surrounded by Graves disease Endemic goiter erythema Thyroid can be palpated Inspect amount and distribution of scalp, Normal to gender Excessive hair loss Thyroiditis body, axillae, pubic hair distribution Infection Normal male pattern Nutritional deficiencies Ask to swallow Felt rising underneath fingers Coarse tissue or irregular consistency may indicate an balding is symmetric Hormonal disorder Lobes should feel smooth, rubbery, inflammatory process Thyroid/liver disease free of nodules Drug toxicity AUSCULTATION Hepatic or renal failure Auscultate thyroid only if enlarged No bruits auscultated Soft, blowing, swishing sound Chemo or radiation hyperthyroidism Patchy hair loss Infections of scalp like DLE, SLE, chemo Hirsutism (facial hair on females) Cushing's disease Polycystic ovary syndrome Imbalance of adrenal hormones Steroid use