Physical Assessment

Question 1

What is a normal assessment of the skin?

Answer 1

1. Evenly pigmented
2. No petechiae, purpura, lesions or excoriation
3. Warm, dry, intact, elastic turgor

Question 2

What is a normal assessment of the nails?

Answer 2

1. Pink, oval, and adhere to the nail bed

Question 3

What is a normal assessment of the hair?

Answer 3

1. Shiny and full
2. Amount of distribution appropriate for age and gender
3. No flaking of scalp or forehead

Question 4

What is the subjective data for a general assessment during the interview process?

Answer 4

1. PMH
2. Medications
3. Allergies
4. Surgery

Question 5

What is the subjective data for assessment of health practice?

Answer 5

1. Hygiene
2. Diet history
3. Elimination
4. Exercise/Activity
5. Sleep/rest
6. Self-concept
7. Values/belief system

Question 6

What subjective data is assessed for medications used and drug reactions?

Answer 6

1. OTC, prescribed or homeopathic
2. Past reactions to meds
3. Photosensitive drugs
4. Side effects of steroids

Question 7

What are some photosensitive drugs?

Answer 7

1. Sulfa
2. Diuretics
3. Tetracycline
4. Doxycycline

Question 8

What are some side effects of steroids relating to the integumentary system?

Answer 8

1. Acne

2. Thinning of skin

Question 9

What subjective data is important for assessment of allergies?

Answer 9

1. Allergy - something that consistently happens when using the same antigen
2. Irritation - unpredictable
3. Fruits - pesticides

Question 10

What is the main question to determine scabies outbreak?

Answer 10

Is the itching so uncomfortable it wakes you out of your sleep?

Question 11

What is the most important factor of assessing skin?

Answer 11

Change is the most important factor

Question 12

What does normal skin look like?

Answer 12

It depends on the melanin

Question 13

What does pale skin look like?

Answer 13

Decreased amounts of Hgb

Question 14

What does blue mean for skin assessment?

Answer 14

Inadequate tissue perfusion with oxygenated blood

Question 15

Deep red

Answer 15

Over abundance of RBCs meaning polycythemia Vera, sunburn, fever, allergic reaction, emotions

Question 16

When inspecting lesions what needs to be documented?

Answer 16

Size
Location 
Color
Distribution 
Shape

Question 17

When inspecting for odors of the skin what assessment needs to be documented?

Answer 17

Unusual smells
Yeast/ bacteria
Intertriginous areas

Question 18

What does intertriginous mean?

Answer 18

In between skin folds

Question 19

Where are common intertriginous areas located?

Answer 19

Axilla, perineal area/groin, under breast, abdominal folds, between digits

Question 20

How many inches at a time to we assess the hair?

Answer 20

1inch blocks

Question 21

What could felt cold skin indicate?

Answer 21

Shock, organ failure, septic

Question 22

How do we assess the temperature of a patients skin?

Answer 22

Using the back of the hand

Question 23

What is assessed about turgor?

Answer 23

Is it elastic, sluggish, inelastic, tenting

Question 24

What does skin turgor indicate?

Answer 24

Hydration status

Question 25

What do we assess relating to moisture of a patients skin?

Answer 25

Are they moist or dry. Keep dry.

Question 26

What do we assess for texture of the skin?

Answer 26

Is the skin smooth, firm, even, calluses (palms/soles) normal

Question 27

What areas do we use to assess dark skin?

Answer 27

``` Lips MM Nail beds Buttocks Palms Soles ```

Question 28

How can we determine a dark skin patient is cyanotic?

Answer 28

They are usually ashen or gray in the eyes, lips, MM, nail beds

Question 29

How can we determine a dark skin patient has eccchymosis/bruising?

Answer 29

It's hard to tell unless they have lightly pigmented skin

Question 30

How can we tell a dark skin patient has erythema?

Answer 30

They will have a deeper brown or purple color and increased skin temp

Question 31

How can we tell a dark skin patient is jaundiced?

Answer 31

Yellow-green eyes | Sclera of the eyes, palms, and soles

Question 32

How can we tell a dark skin patient has Petechiae?

Answer 32

It is difficult to see but use the bucca mucosa and eyes

Question 33

How can we determine if a dark skin patient has rashes?

Answer 33

May need to palpate raised area

Question 34

What is normal about the nail pigment of a dark skin patient?

Answer 34

Dark linear streaks on nail plate (normal over 90% of dark skin)

Question 35

Disorders that directly affect skin color are?

Answer 35

``` Activity UV exposure Emotions Cigarette smoking Edema Respiratory and cv system Renal and hepatic function ```

Question 36

If the skin is not blanchable it means what?

Answer 36

Related to Sub Q or intradermal bleed

Question 37

What is linear?

Answer 37

Forming a line | Ex. Poison oak rash

Question 38

What is annular?

Answer 38

``` Ring-like Ex. Ringworm, iris-target lesion Concentrated rings "Bulls eye" Ex. Erythema multiforme ```

Question 39

What is dermatomal?

Answer 39

Follows a nerve path | Ex. Shingles

Question 40

All biopsies need a what?

Answer 40

Consent signed

Question 41

When a lesion is draining what is normally done?

Answer 41

A culture is sent out