3) Quick Neuro + Integuement assessment.pdf

NUR350: Health Assessment Week 3 Quick Neuro Check & Integument Assessment M AR Y AN N F EG A N RN , M N A S S OC I ATE P R OF E S S OR , TE AC H I N G S TR EA M  Learning Outcomes At the end of this week, you will be able to: 1. Describe the components of a quick neuro check 2. Identify the an...

NUR350: Health Assessment Week 3 Quick Neuro Check & Integument Assessment M AR Y AN N F EG A N RN , M N A S S OC I ATE P R OF E S S OR , TE AC H I N G S TR EA M  Learning Outcomes At the end of this week, you will be able to: 1. Describe the components of a quick neuro check 2. Identify the anatomical structures and functions of the skin, hair & nails 3. Discuss the expected developmental and cultural variations in the assessment of the integument 4. Describe the subjective and objective integument assessments 5. Explain skin self-examination 6. Identify and describe primary, secondary and vascular lesions 7. Lab Practice – Perform a quick neuro check and assessment of the skin, hair and nails Why review and explore Chapter 29?? Jarvis, C. & Eckhardt, A. (2024). Bedside assessment and electronic health recording. In A.J. Browne, J. MacDonald-Jenkins & M. Luctkar-Flude (Eds.), Physical examination & health assessment (4th Canadian ed., pp. 856-864). Elsevier. Brings us back to week 1 and week 2 learning… What do we do with all this subjective and objective data? Highlights importance of documentation and communication of our assessment findings ◦ Electronic health record (EHR) and/or electronic medical record (EMR) securely and privately record a person’s health information ◦ Nurses use this information to support clinical decision making and nursing practice improvements and use standardized nursing and other clinical terminology The Quick Neuro Check at the begining of the assessment when we initially see the patient first Level of Consciousness ◦ Alert not fully alert, drifiting off to sleep while talking to them ◦ Lethargic transition between lethargy and stupor ◦ Obtunded ex: patient is sleeping most of time and difficult to arrouse need to shout or shake them and after they're awake they're confused, mumbling sleep need continuous stimulation to stay engaged ◦ Stupor semi-coma a patient that is spontaneously unconsious, repsond to only persistant and vigrous ◦ Coma shaking, or a painful stimulus (sternal rub), they have a response to pain but otherwise groan or mumbles restlesly - Orientation to person, place and time patient completly unconscious and doesn't respond ANO x3 - alert and oriented to any painful stimulus Communication speech is clear and articulate Motor response grip your hands, push feet against your palms  Integument Assessment inspecting and palpating skin, nails, and heair should always be part of our physical assessment in the avg adult skin covers 1.68 square metres of area Developmental Considerations Infants ◦ Lanugo hair follicles develop at 3 months gestation, by the last months of gestation skin is covered with lanugo - fine downy hair this hair falls out after a few months and gets replaced with fine vellus hair ◦ Vernix middle pic, sebum and shed epitheleial cells, seabum helps skin hold water, it acts as a protective measure for their thin and more permeable skin ◦ Milia some infants develop this, right pic, small white bumps or cradle cap on scalp, these are a result of excess seabum on skin during first few weeks of life, the sebeacous glands decrease in size and production of seabum decrease and don't resume function until puberty ◦ Eccrine glands not functional during first few months of life ◦ Subcutaneous layer inefficient thus they cannot regulate their own temp Developmental Considerations Adolescents Adolescents ◦ Increased secretion from the apocrine glands ◦ Sebaceous glands become more active ◦ Subcutaneous fat deposits increase most promineent in female body Developmental Considerations Pregnant Persons 3 ◦ Linea nigra direct result from the change in hormone level in the areola, nipples, vulva, and sometimes the midline of abdomen ◦ Cholasma fades away after pregnancy - ◦ Striae gravidarum after skin is back to normal it's been strethecd AKA stretchmarks  Developmental Considerations Aging Adult at risk for shearing and tearing injuries, older people often need an extra layer of clothes to stay warm Skin folds and sags especialy for those with limited mobility and > - increased fall risk spend time in bed/chairs ◦ Decreased elastin, collagen, subcutaneous fat & muscle tone ◦ Sweat and sebaceous glands decrease in number and function poor temp regulation, greater heat stroke risk, dry skin Hair ◦ Decreased melanocytes = finer hair and white colour ◦ Hair distribution changes Nails ◦ Grow more slowly with more prominent longitudinal ridges  Assessment of the Integument Subjective Data Previous history of skin disease allergies, birthmarks Change in pigmentation Change in a mole Excessive dryness or moisture Pruritus itchiness, mild or intense? Excessive bruising Rash or lesion where were they, spread, pain?, what alleviates etc ◦ PQRSTUAAA Medications any recent change to medications? could be a reaction Hair loss Change in nails Environmental or occupational hazards Self-care behaviours sunscreen, what soap do they use etc Assessment of the Integument: Objective Data Before you begin: ex: patient is embaresed = blush and we ◦ Be aware of external variables that may distort your findings think it's a finding or if they're cold ◦ Don’t gloss over skin assessment- it’s important! ◦ Be aware of the patient’s/client’s baseline skin characteristics ◦ Don’t forget hidden areas skin folds ◦ Try to incorporate into the physical assessment or during bathing  Important Resources for Practice: Brown Skin Matters: @brownskinmatters Mukwende, M., Tamony, P & Turner, M. (2020). Mind the Gap: A handbook of clinical signs in Black and Brown skin. Online publication, St. George's University of London. London,UK. https://sgul.figshare.com/articles/online_resource/Mind_the_Gap_A_h andbook_of_clinical_signs_in_Black_and_Brown_skin/12769988 Skin Deep: www.dftbskindeep.com  No percussing or ascultating this system Inspect and Palpate the Hair Colour Texture keeping in mind age related changes that occur Distribution checking for lesions or head lice, checking for excessive hair on skin Lesions which may be a hormonal imbalance make sure to assess the scalp  nail clubbing Inspect and Palpate the Nails Shape and contour Consistency should feel firm on palpation Colour check capilary refil which shows how well blood flows through peripheral tissues and it's a good indication of hydration status, note the time it takes for the colour to return, normal refil time is less than 3 seconds expected finding in darker skin heart and lung disease symptom  Inspect and Palpate the Skin paleness, loss of healthy pink undertones from poor oxygenation resulting in anemia or shock or vasoconstriction as an Colour environemntal variable if the client was cold ◦ Pallor> can also be assessed in the conjuctiva of the lower eyelid ◦ Erythema intense redness of the skin, from excess blood in the dialated superficial capilaries, expected with ◦ Cyanosis those who have local inflamation or fevers, or 3 ◦ Jaundice emotional reactions such as blushing bluish discolourition Temperature associated with decreased blood flow and indicates poor tissue Moisture perfusion inadequate oxygenation Texture yello discolouriation indicating inc Thickness bilirubing in the blood, can be expected in the Edema newborn, otherwise fluid accumilating in this is not expected intercellular spaces and and can be assesed in isn't expected to the mouth, scelera and the skin pitting edema is when your thumb leaves a dent in the skin Edema edema is usually gradded on a 4 point scale 4 point scale ◦ 1+= mild pitting, slight indentation, no perceptible swelling ◦ 2+= moderate pitting, indentation subsides rapidly ◦ 3+= deep pitting, indentation remains for a short time, limb looks swollen ◦ 4+= very deep pitting, indentation lasts a long time, limb is very swollen this picture  Inspect and Palpate the Skin elasticity of skin, best place is the anterior aspect of the chest under the clavicle Mobility and turgorhow promptly it returns to original position after being pulled how easily it's being pulled Vascularity or bruising can be caused by trauma, bleeding disorders or liver dysfunction Lesions  Lesions caused by abuse or trauma expected colour changes of a bruise overtime if there is a discrepency between the history of when the bruising happened vs what colour it is could be a hint to abuse Assessment of Lesions 1. Colour 2. Elevation 3. Pattern or shape, the grouping or distinctness of each lesion 4. Size, in centimeters not pea sized, determine the acc measurment 5. Location and distribution on body localized to a certain area or all over 6. Any exudate; colour and/or odour  Danger Signs in Pigmented Lesions ABCDE! ◦ Asymmetry not round/oval ◦ Border irregularity ◦ Colour variation ◦ Diameter greater than 6mm ◦ Elevation and evolution  Health Promotion! Teach Skin Self- Examination Figure 13.12 Describe the Shape & Configuration of Skin Lesions Annular Confluent Discrete aka circular lesions, begins in centre and lesions merging togetehr distinct and individual lesions sprads to periphery Ex: hives that remain seperate ex: ringworm Ex; wart or mole Describe the Shape & Configuration of Skin Lesions Grouped Gyrate Target clustered, contact dermetities twisted lesion, coiled, spiral or snake like AKA: iris resembling the iris of an eye, concentrict rings ex; lime disease Describe the Shape & Configuration of Skin Lesions Linear Polycyclic Zosteriform annular/circular lesion that grow togetehr linear arangment of lesions along a look like s cartch, line, streak ex: psoriasis nerve root ex: cut ex: shingles, herpes zorster  3 categories of lesions, primary, secondary, and vascular 1. Primary Skin Lesions develop on previosluy unaltered or healthy skinand Macule Tumor Patch Urticaria Papule Vesicle Plaque Bulla Nodule Cyst Wheal Pustule  PATCH: a macule greater than 1 cm in diamtere ex: a pigmented birthmark or a larger flat mole Macule and Patch mangolian spot on back of infant "cafee au lait" because looks like the colour of coffee Macule: a colour change, flat and self contained, and less than.1 cm diamater ex: freckle, mole or measles solid elevated self contained less than 1 cm in papules that join togetehr forming a diameter and is a thickening of the epidermis surface area wider than 1 cm ex: elevated mole or wart disk shaped lesions, such as psorisis in & the picture on bottom Papule and Plaque solid and elevated and can be hard or soft and it's greater than 1 cm in diameter, can extend deeper into the dermis than a papule, it may be above, leved with or below the skin surface Nodule and Tumour larger than 2 cm in diameter, can be firm or soft, extendes deeper into dermis superficial, raised and transient, it's a reddened area slightly irregular in shape because of edema AKA hives, wheals joining togetehr to form an extensive reaction and they're very ex: mosquito bite or alergic reaction itchy Wheal and Urticaria a blister, elevated cavity containing fluid up to 1 cm in diameter and clear fluid flows out if wall is ruptured Vesicle and Bulla ex: early chicken pox or shingles single chambered, superficila, greater than 1 cm in diameter and is thin walled so ruptures easily ex: burns encapsulated fluid filled cavity in the dermis or subcutaneous tissue, tensley cavity filled with puss, selfcontianed and elevated an elevates the skin example is acne ex: sebeacous cyst Cyst Pustule  results from a change in a primary lesion overtime an evolutionary change 2. Secondary Skin Lesions Crust Excoriation Scale Scar Fissure Atrophic Scar Erosion Lichenification Ulcer Keloid thickened dried out exudate left compact desicated flakes of skin and can be dry or greasy, when vesicles or pustules burst silvery or white this comes from shedding of dead excess or dry and colour can vary keratin cells similar to a scab dry skin, psiriosis, eczema Crust both are debris on skin surface Scale  scooped out but shallow/superficial depresion in the epidermis, moist but has no bleeding because epidermis is avascular and heal without a scar linear crack with abrupt edges extending into dermis because it doesn't extend into the dermis dry or moist ex: dermatitis or an abrasion Fissure Erosion  self-inflicted abrasion, superficial, someties crusted and ususly results from scratching an itch intensley or an deeper depresion extending into dermis, animal scartch or picking of a pimple irregualr shape, bleads, and leaves a scar these often scar Ulcer Excoriation  made up of collagen/connective tissue that repalces normal tissue after a skin depresion of skin level as a result of loss of skin tissue, thining of the lesion is repaired epidermis ex: striae (stretch marks) it's a permanant fibrotic change in Scar the skin Atrophic Scar thickneing of skin with production of elevated by excess scar tissue which is a result of sets of papules caused by prolonged excess collagen production during the wound intense scrathcing healing process loos smooth, rubery Lichenification Keloid 3. Vascular Lesions Hemangiomas Telangiectases Purpuric Lesions  Vascular Lesions caused by a benign proliferation of blood vsessels in the dermis Hemangiomas ◦ Port wine stain large flat macular patch covering scalp or face, dark red'bluish or purple ish, present at birth usually don't fade raised red area with well-defined borders, 2-3cm in diameter and does not blanch with pressure - formed by immature ◦ Strawberry mark capilaries, present at birth and usually disapera by age 5-7 ◦ Cavernous hemangioma reddish blue irregulary shape solid spongey mass of blood vessels - may be at birth and enlargened during first years of life they don't go away on their own  Vascular Lesions appearance of blood vessels on the skin's surface Telangiectases ◦ Telangiectasia occurs when blood vessels are permenanly enlarged and dialated (left pic) AKA spider veins ◦ Spider or Star angioma firey red star shaoe marking with a solid circle centre (middle pic0 ◦ Venous Lake blue purple dilation of smaller blood vessels and capilaries in a star hsaped, linear or flaring pattern often on the legs common in older population  caused by blood leaking out both of these can occur in people with thrombocytopenia where someon has a Purpuric Lesions of the vessels (red blood cells dpeosited into the tissues) low blood platelet count Petechiae tiny hemorhages, round, discrete 1-3mm bleeding from superficila capilaries into the skin and don't blanch excessive patch of petichiae, greater than 3 mm in size Purpura can occur in older people from minor trauma This week’s practice: Engage: ◦ Apply your knowledge and understanding while completing a virtually facilitated case study! Watch: ◦ Assessing the Skin, Hair and Nails Complete and submit your pre-lab Quiz! Lab: ◦ Work with your partner to perform a quick Neuro Check and Integumentary Assessment on each other ◦ Bring the checklist to help guide your approach and practice Perform a quick neuro check and aspects of the integument assessment on your client/patient this week in clinical!