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NURS 190 Physical Assessment Final Exam.
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NURS 190 Physical Assessment Final Exam./ NURS 190 Physical Assessment Final Exam.
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Physical Assessment Final ExamJanuary 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
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