Pallor

Define

Causes

- Loss of skin color due to absence of oxygenated hemoglobin

- caused by vasoconstriction from cold, smoking or stress.  Also by decreased tissue perfusion caused by COPD, shock, hypotension, lack of O2, or prolonged elevation of a body part.  Also by anemia.

Pallor

Appearance in light skin

Appearance in dark skin

- White skin loses rosy undertones.  Skin with yellow tones appears more yellow; may be mistaken for jaundice.

- Black skin loses its red undertones appears ashe gray.  Brown becomes yellow tinged.  Skin looks dull.

Cyanosis

Define

Causes

Lt Skin

Dark Skin

-Blue color due to lack of oxygenated blood

-Systemic caused by cardiac disease, pulmonary disease, heart malformations and low hemoglobin levels. Localized caused by vasoconstriction, cold or stress.

-White skin, lips and mucousa are blue tinged.  Also conjunctivae and nails.

-Black skin may appear darker.  May be unseen except for lips, tongue, mucousa, nails and conjunctivae.

Edema Scale

2 mm - +1

4 mm - +2

6 mm - +3

8 mm - +4

Diaphoresis

define

profuse sweating

Tenting

define

cause

- holds its pinched form and slowly returns

- caused by dehydration or extreme weight loss

ABC's of Melanoma Assessment

A - Asymmetry

B - Border irregularity

C - Color variation

D - Diameter greater than 6mm

E - Evolving changes

Graying hair caused by ....

possibly a nutritional deficiency commonly protein or copper

Dull, dry, brittle hair caused by ...

possibly hypothyroidism

Primary lesions

1) macule, patch; flat, nonpalpable change in skin color.  Macule less than 1cm, patch > 1cm ex: freckles, measles, mongolian spots, vitilgo

2) papule, plaque: elevated solid palpable mass w/regular borders.  papule < .5cm, plaque > .5cm ex: moles, warts, psoriasis

3) nodule, tumor: hard or soft palpable mass extending into dermis nodules <2 cm irregular borders ex: lipomas, carcinomas

4) vesicle, bulla: elevated, round, fluid filled palpable mass vesicle < .5cm; chickenpox, burn blisters

Bruit

-heard with

-means

-define

- the bell of stethoscope

- stenosis (narrowing) of a vessel

- is a soft blowing sound

Pallor

(Appearance in light skin people)

White skin loses its rosy tones skins w/natural yellow tones appears more yellow; may be mistaken for mild jaundice.

Pallor

(Appearance in dark skin)

Black skin loses its red undertones and appears ash-gray.  Brown skin becomes yellow-tinged.  Skin looks dull.

Cyanosis

(Appearance in light skin)

The skin, lips, and mucous membranes look blue-tinged.  The conjunctivae and nail beds are blue.

Cyanosis

(Appearance in dark skin)

The skin may appear a shade darker.  Cyanosis may be undectable except for the lips, tongue and oral mucous membranes, nail beds, and conjunctivae which appear pale or blue-tinged.

Jaundice

Appearance in light skin

Generalized.  Also visible in sclerae, oral mucosa, hard palate, fingernails, palms of hands and soles of the feet.

Jaundice

(Appearance in dark skin)

Visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands & soles of the feet.

Steps in inspection of the skin

1) Observe for cleanliness & use the sense of smell to determine body odor.

2) Observe the client's skin tone.

3) Inspect the skin for even pigmentation over the body.

4) Inspect the skin for superficial arteries & veins.

Palpation of the skin

1) Determine the client's skin temp.

2) Assess the amount of moisture on the skin surface.

3) Papate the skin for texture.

4) Palpate the skin to determine its thickness.

5) Palpate the skin for elasticity.

6) Inspect & palpate the skin for lesions.

7) Palpate the skin for sensitivity.

Primary lesions

Develop on previously unaltered skin.

Secondary lesions

Lesions that change over time or because of scratching, abrasion or infection.

ABCDE - Criteria for Melanoma Assessment

A - Asymmetry

B - Border irregularity

C - Color variegation

D - Diamater greater than 6mm

E - Evolving changes

Grading on edema

* Palpation leaves a dent

* The fluid of edema lies above the pigmented & vascular layers of the skin, skin tone in the client w/edema is obscured.

2mm = +1

4mm = +2

6mm = +3

8mm = +4

Hair assessment

General assessment

Assessment of nails

1) Assess for hygiene

2) Inspect the nails for an even, pink undertone.

3) Assess capillary refill.

4) Inspect & palpate the nails for shape & contour.

5) Palpate the nails to determine their thickness, regularity & attachment to nail bed.

6) Inspect & palpate the cuticles.

Assess capillary refill

Depress the nail edge briefly to blanch & then release.  Color returns to healthy nails instantly upon release.

Inspect & palpate the nails for shape & contour

*Perform the Schamroth technique to access clubbing.

Ask client to bring the dorsal aspect of corresponding fingers together, creating a mirror image.

* Look at the distal phalanx & observe the diamond-shaped opening created by nails.  When clubbing is present, the diamond is not formed and the distance increases at the fingertip.

Continued on nails

*The nails normally form a slight convex curve or lie flat on the nail bed.  When viewed laterally, the angle between the skin and nail bed base should be approximately 160 degrees.  Greater than 160° is clubbing.

Assessing the head

1) Inspect the head & scalp.

2) Inspect the face.

3) Observe movements of the head, face & eyes.

4) Palpate the head & scalp.

5) Confirm skin & tissue integrity.

6) Palpate the temporal artery.

7) Auscultate the temporal artery.

8) TEST the range of motion of the TMJ.

Palpate the sinuses

*Begin by pressing your thumbs over the frontal sinuses below the superior orbital ridge.  Palpate the maxillary sinuses below the zygomatic arches of cheekbones.

*Observe the client for signs of discomfort.  Ask client to inform you of pain.

Percuss the sinuses

*To determine if there is pain in the sinuses, directly percuss over the maxillary and frontal sinuses by lightly tapping w/one finger.

Transilluminate the sinuses

*If you suspect a sinus infection, the maxillary & frontal sinuses may be transilluminated.

*To transilluminate the frontal sinus, darken room & hold a penlight under the superior orbit ridge against the frontal sinus area.

*Cover it with your hand.  There should be a red glow over the frontal sinus area. 
*To test the maxillary sinus, place clean penlight in the pt's mouth & shine the light on one side of the hard palate, then the other.

*There should be a red glow over the cheeks.  Make sure the penlight is cleaned before using it again.

*An alternate technique is to place the penlight directly on the cheek & observe the glow of light on the hard palate.

Assessing temporal artery

*Palate between the eye and the top of the ear.  The artery should feel smooth.

*Use the bell of the stethoscope to auscultate for a bruit (a soft blowing sound).  Bruits are not normally present.

Assessing the TMJ

*Place your fingers in front of each ear & ask client to open & close mouth slowly.  There should be no limitation of movement or tenderness.  You should feel a slight indentation of the jont.  Soft clicking noises on movement are sometimes heard and are considered normal.

Assessing the neck

1) Inspect the neck for skin color, integrity, shape & symmetry. 

2) Test range of motion of the neck.

3) Observe the carotid arteries & jugular veins.

4) Palpate teh trachea.

5) Inspect the thyroid gland.

6) Palpate the thyroid gland from behind pt.

7) Palpate the thyroid gland from in front of pt.

8) Ausculate the thyroid.

9) Palpate the lymph nodes of the head & neck.

Testing of the 6 cardinal fields of gaze

1) position client - the client is sitting in a comfortable position.  You are @ eye level w/client

2) instruct the client - explain that you will be testing eye movements & the muscles of the eye. Explain that client must keep the head still while following a pen or penlight that you will move in several directions in front of client's eye.

3) State about 2ft (0.6m) in front of the client.

4) Letter "H" method.  Starting @ midline, move the penlight to the extreme left, then straight ↑ then straight ↓

*Drop your hand.  Position the penlight against the midline.

*Now move the penlight to the extreme right, then straight up, then straight down the center before changing direction.

Pupil

Size & Shape

Normal size 4-5 mm, round

Consceinsus

Both eyes react together.

PERRLA

Pupils Equal Round React to light & Accomonation

Assess Sclera

& conjunctiva

Press the lower lid against the lower orbital rim & have client look up.  Conjunctiva should be pink with no tenderness or irregularities.

Sclera should be white.

What do pupils do focusing on distance/close

Distance - dilate

Close - constrict

Otoscope inspection of ear canal

Pt should tilt head to opposite shoulder.  In adults pull the pinna up, back, & out to straighten the canal.

The canal should be open with no tenderness, inflammation, lesions, growths, discharge or foreign substances.  Note the amount of cerumen the texture & color.

The Rinne Test

Weber Test

Strike tuning fork with palm.  Hold base against the medial portion of the frontal bone.  Sound should be heard equally in both ears.

Romberg Test

Assess equilibrium

Have pt stand with feet together & eyes open at first then clsoed.  Mild swaying equals negative test.

Assess Nose

Ensure skin is intact & check for drainage.  Palpate for tenderness listen for noises during respiration.

Assess Mouth

Note lips intact & color.  Inspect teeth for color, hygiene, gums, tongue, buccal should be moist, pink, smooth & free of legions.  Note odors.

Assess Throat

Using a tongue blade & penlight move tongue & have pt say "aoh" to move avula.  Ensure tonsils, uvula & pharyx are pink & without lesions or inflammation.