NURS 190 PHYSICAL ASSESSMENT FINAL EXAM JANUARY 15TH, 2019
5 views 0 purchase
Course
NURS 190 PHYSICAL ASSESSMENT
Institution
Walden University
NURS 190 PHYSICAL ASSESSMENT FINAL EXAM JANUARY 15TH, 2019
Inspection technique (3):
● FIRST technique with general survey
● General survey:
○ Observing mobility / gait, physical appearance, general wellness/health, mood & behavior (facial expressions, interactions), mental status (o...
nurs 190 physical assessment final exam january 15th
nurs 190 physical assessment final exam january 15th
2019 inspection technique 3 ● first technique with general survey ● general surve
Written for
Walden University
NURS 190 PHYSICAL ASSESSMENT
All documents for this subject (5)
Seller
Follow
NURSEREP
Reviews received
Content preview
NURS 190 PHYSICAL
ASSESSMENT FINAL EXAM
JANUARY 15TH, 2019
Inspection technique (3):
● FIRST technique with general survey
● General survey:
○ Observing mobility / gait, physical appearance, general
wellness/health, mood & behavior (facial expressions, interactions),
mental status (observing patient’s body language and response when
asking questions)
● Do it the SAME WAY every time → less likely to forget something
● Do not rush it, especially with anxious patients
○ Make sure the patient is comfortable
○ Temperature in the room is suitable for the patient
● Make sure that you have everything that you need → so that the
patient has confidence in you
● Know normal vs abnormal when surveying appearance & symmetry
○ Compare ANYTHING that has a pair
○ Eyes- level, equal, is there eyelid drooping?
○ Smile- is there a droop?
○ Always compare the two sides to ensure that there is no abnormality
between the two sides
● Listen for natural sounds
○ Abnormal sounds: wheezing, labored breathing, crepitus during ROM
● Detect abnormal odors:
○ CDIFF, alcohol on a patient, acetone / sugary breath
● Try not to assume anything ! → use critical thinking!
○ Ex: someone with low blood sugar or issues with hypoxia can appear
intoxicated
● Know your normal values:
○ Blood pressure, HR, RR, O2 sats, temperature
○ For each age levels
■ Infants: must faster RR than elderly
Percussion technique (3)
● Types:
○ Direct percussion- tapping body with fingertips of dominant hand
■ For a small infant → direct percussion on the chest
■ Adult → on the sinuses on the face
○ Blunt percussion- place palm of nondominant hand flat against the
surface and strike it with closed-fist dominant hand
■ Used to assess the kidneys → assessing for pain / tenderness
, (UTI)
○ Indirect percussion- most commonly used
■ Plexor = hammer or tapping finger
■ Pleximeter = device or surface that accepts the tap
● Sounds:
○ Intensity of amplitude: softness or loudness
○ Pitch or frequency: high or low (vibrations per second)
○ Duration: length of time
○ Quality: recognizable overtones or drumlike sounds
● Tympany- sound heard over stomach or intestines
○ Loud, high-pitched, drum-like tone
● Resonance- normal sound heard over lungs
○ Loud, low-pitched, hollow tone
● Hyperresonance- air trapped in lungs
○ Abnormally loud, low tone of longer duration than resonance
■ COPD, trauma or lung collapse
● Dullness- over solid body organs (liver)
○ High-pitched tone, soft and short
● Flatness- over solid tissue, muscle, or bone
○ High-pitched tone, very soft & shorter than dullness
■ Ex: ribs
Skin assessment (5)
● Life span considerations:
○ Infants and children
■ Newborn skin → covered with vernix caseosa
■ Infants have thin, soft, skin and free of hair
■ Milia and stork bites- common, harmless markings in newborns
■ Mongolian spots- gray, blue or purple spots in sacral and buttocks area
● Fade by age 3
● Try not to confuse it with possibility of abuse →
ask the parent “is this something that has been here
since birth?”
■ Poor temperature regulation → do not secrete from glands
○ Pregnant female
■ Skin pigmentation increases → in areolae,
nipples, vulva, perianal area
● Development of melasma and linea nigra down the abdomen
● Resolve itself after pregnancy
■ Hormonal changes→ cause oil and sweat glands to
become hyperactive
● Acne worsens in 1st trimester
■ Hair may fall out during months 1-5
○ Older adult
■ Skin elasticity decreases with aging
, ■ Sebum production decreases → causes dryness
● More prone to skin breakdown
■ Perspiration / sweating decreases
■ Decrease in melanin production → result in gray hair
■ Nails become thicker and more brittle due to decreased
amount of circulation
■ Hair thins because of decrease of hair follicles
■ Liver spots, hyperpigmented freckles, increased amount of skin tags
● Psychosocial considerations:
○ Stressed induced illness:
■ Trichotillomania- hair twisting & pulling
■ Nail biting
■ Visible skin disorders in relation to self-esteem / body image
● Cultural and environmental considerations:
○ Socioeconomic status
■ Not able to go to the doctor because of finances
○ Home environment
■ Are they homeless? → if so, could be more likely to
develop skin cancer due to outside exposure
○ Means of employment
■ If they work outside → important to know
■ Do not assume bad hygiene!! → could be from work
○ Changes in skin color → may be more difficult to detect in
patients with dark skin
○ Dry skin does not necessarily indicate dehydration
○ Skin response to stressors differ from person to person
■ Autoimmune disorders
○ Differences in hair color and texture vary from different cultural groups
○ Prolonged immersion of hands in water can cause paronychia-
reddened cuticles causing infection
○ Table 13.2 (variations) 31:28
● Focused interview- questions related to:
○ Notice any smells / foul odors
○ Changes in color → oxygenation issues or perfusion
○ Sweating → fever, being in the sun too long, excessive sweating
○ Skin:
■ In general
■ Illness or infection
■ Symptoms, pain, behaviors
■ Age
■ External environment
○ Hair:
■ In general
■ Infants and children
, ○ Nails:
■ In general
■ Infants and children
■ Pregnant females
■ Older adult
● Color variations in light and dark skin
○ Pallor- loss of color in skin due to absence of oxygenated hemoglobin
■ Light skin:
● White skin loses rosy tones
● Yellow tone appears more yellow
■ Dark skin:
● Black skin loses its red undertones and appears ash-gray
● Brown skin becomes yellow-tinged
○ Absence of color- loss of pigment
■ Albinism- white/pale blond hair and pink irises
■ Vitiligo- very noticeable as patchy milk-white areas
■ Tinea- appears patchy areas paler than surrounding skin
○ Cyanosis- blue color in skin due to inadequate tissue perfusion
■ Light skin:
● Skin, lips, mucous membranes look blue-tinged; nail beds are blue
■ Dark skin:
● May appear a shade darker
● May be undetectable except for lips, tongue, oral
mucous membranes, nail beds, and conjunctivae
○ Reddish blue tone- ruddy tone due to increased hemoglobin and stasis of blood
■ Light skin: reddish purple hue
■ Dark skin: difficult to detect; normal skin may appear
darker in some patients
○ Erythema- redness of the skin due to increased visibility
of normal oxyhemoglobin
■ Light skin: local inflammation and redness
■ Dark skin: hard to detect; inflammation appear purple or
darker than surrounding skin
○ Jaundice- yellow undertone due to increased bilirubin
■ Generalized; visible in sclera, oral mucosa, hard palate,
fingernails, palms of hands, and soles of the feet
Skin lesions (5)
● Primary lesions:
○ Macule and patch- flat, nonpalpable change in the skin color
■ Macule: Smaller than 1 cm
■ Patch: larger than 1 cm
○ Papule and plaque- elevated, solid palpable masses with a circumscribed
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller NURSEREP. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.49. You're not tied to anything after your purchase.
