Download NR302 / NR 302: Health Assessment Exam 2 Review (Latest 2021 / 2022) Chamberlain College o and more Study notes Nursing in PDF only on Docsity!
EXAM 2 REVIEW CHECK OF KNOWLEDGE
SKIN, HAIR, NAILS, HEAD, FACE, AND REGIONAL LYMPHATICS: CHAPTER
NR 302 Exam 2 Review
Let this be a review check of your studies, but also assessment will include class presented content, your assigned readings and resources. Don’t forget to practice your assessment checkoff skills on your return demonstration form those are the techniques you will be tested on as they apply to the content below.
1. Describe the function of lymph nodes and explain the technique approach
when assessing lymph nodes.
- To detect and eliminate foreign substances from the body. The vessels gather the clear, watery fluid (lymph) from the tissue spaces into the circulation. The nodes slowly filter the lymph and engulf pathogens, preventing harmful substances from entering the circulation.
- Using a gentle circular motion of your finger pads, palpate the lymph nodes. Beginning with the preauricular lymph nodes in front of the ear, palpate the 10 groups of lymph nodes in a routine order. Many nodes are closely packed, so you must be systematic and thorough in your examination. Once you establish your sequence, do not vary or you may miss some small nodes. Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, comparing the two sides symmetrically. However, the submental gland under the tip of the chin is easier to explore with one hand. When you palpate with one hand, use your other hand to position the person's head. For the deep cervical chain, tip
2. Technique of inspections of the head, face and neck and its normal and
abnormal findings
1. Head - Note the general size and shape. To assess shape, place your fingers in the person's hair and palpate the scalp. - Normal Findings- The skull normally feels symmetric and smooth. Cranial bones that have normal protrusions are the forehead, the side of each parietal bone, the occipital bone, and the mastoid process behind each ear. There is no tenderness to palpation. - Abnormal findings- lumps, depressions, or abnormal protrusions. Deformities: microcephaly, abnormally small head;
2. Face 3. Neck macrocephaly, abnormally large head (hydrocephaly, acromegaly)
- Inspect the face, noting the facial expression and its appropriateness to behavior or reported mood. Although the shape of facial structures may vary somewhat depending on ancestry, features always should be symmetric. Also note any involuntary movements (tics) in the facial muscles. Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation) or any abnormal swelling.
- Normal findings- Anxiety is common in the hospitalized or ill person. Expect symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of the mouth.
- Abnormal findings- Hostility or aggression. Asymmetry with central brain lesion (e.g., stroke) or peripheral cranial nerve VII damage (Bell palsy). Abnormal Facies with Chronic Illness. Edema in the face occurs first around the eyes (periorbital) and the cheeks where the subcutaneous tissue is relatively loose. Note grinding of jaws, tics, fasciculations, or excessive blinking.
- Head position is centered in the midline, and the accessory neck muscles should be symmetric. Note any limitation of movement during active motion. Ask the person to touch the chin to the chest, turn the head to the right and left, try to touch each ear to the shoulder (without elevating shoulders), and extend the head backward. When the neck is supple, motion is smooth and controlled. Test muscle strength and the status of cranial nerve XI by trying to resist the person's movements with your hands as the person shrugs the shoulders and turns the head to each side. Also note any obvious pulsations.
- Normal Findings- The head should be held erect and still.
- Abnormal findings- Head tilt occurs with muscle spasm. Rigid head and neck occur with arthritis. Note pain at any particular movement.
- Note ratchety or limited movement from cervical arthritis or inflammation of neck muscles. The arthritic neck is rigid; the person turns at the shoulders rather than at the neck. Thyroid enlargement may be a unilateral lump, or it may be diffuse and look like a doughnut lying across the lower neck
3. Define a bruit, describe its significance, and describe the sound it makes.
- Bruit- This is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. The bruit is not present normally. A bruit occurs with accelerated or turbulent blood
as minerals, sugars, amino acids, cholesterol, uric acid, and urea.
- Production of vitamin D- The skin is the surface on which ultraviolet (UV) light converts cholesterol into vitamin D.
6. Normal and abnormal findings of the skin: color, temperature, moisture,
texture, edema, turgor
1. Color - Use ABDCE for moles, freckles and birth marks - A symmetry (not regular round or oval or look the same) - B order irregularity (ragged edges, poorly defined margins) - C olor variation (areas of brown, tan, blue, red, or combination) - D iameter (greater than 6mm or pencil eraser) - E levation - Normal- even and consistent with genetic background. - Abnormal- Vitiligo, pallor, erythema, cyanosis, jaundice, ashen or gray 2. Temperature - Normal- warm and equal bilaterally - Abnormal- hypothermia (Temp. low) and Hyperthermia (Temp. high) 3. Moisture - Normal-Perspiration - Abnormal- Diaphoresis(profuse perspiration), dehydration 4. Texture - Normal- smooth and firm with even surface - Abnormal- smoother like velvet, rough, dry, flaky 5. Edema 6. Turgor - Normal- return to place, good elasticity - Abnormal- skin stands by itself
7. Normal and abnormal findings of Hair
- Normal- clean, free of lesions, dandruff, fine, thick, straight, curly, kinky, shiny
- Abnormal- alopecia, dull, coarse, brittle scalp hair, hirsutism,
lice
8. Abnormal findings Table 12 - 2; Pressure Ulcers table 12 - 6 (staging
differences)
Table 12 - 2
Etiology Light Skin Dark Skin
Pallor Anemia—Decreased hematocrit Shock—Decreased perfusion, vasoconstriction
Generalized pallor Brown skin appears
yellow-brown, dull;
black skin appears
ashen gray, dull; skin
loses its healthy glow—
Check areas with least
pigmentation such as
conjunctivae, mucous
membranes
Local arterial insufficiency Marked localized pallor (e.g., lower extremities, especially when elevated)
Ashen gray, dull; cool to
palpation
Albinism—Total absence of pigment melanin throughout the integument
Whitish pink Tan, cream, white
Vitiligo—Patchy depigmentation from destruction of melanocytes Patchy milky-white spots, often symmetric bilaterally
Same
Cyanosis
- Table 12 - 6
- Stage 1- Intact skin appears red but unbroken. Localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure). Dark skin appears darker but does not blanch.
- Stage 2- Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed.
- Stage 3- Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see infections (^) jaundice; jaundice best noted in junction of hard and soft palate and also palms Carotenemia—Increased serum carotene from ingestion of large amounts of carotene- rich foods Yellow-orange in forehead, palms and soles, nasolabial folds, but no yellowing in sclera or mucous membranes Yellow-orange tinge in palms and soles Uremia—Renal failure causes retained urochrome pigments in the blood Orange-green or gray overlying pallor of anemia; may also have ecchymoses and purpura Easily masked; rely on laboratory and clinical findings Brown-Tan Addison disease—Cortisol deficiency stimulates increased melanin production Bronzed appearance; an “eternal tan,” most apparent around nipples, perineum, genitalia, and pressure points (inner thighs, buttocks, elbow, axillae) Easily masked; rely on laboratory and clinical findings Café au lait spots—Caused by increased melanin pigment in basal cell layer Tan to light brown, irregularly shaped, oval patch with well-defined borders
subcutaneous fat but not muscle, bone, or tendon.
- Stage 4 - Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue. Exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue).
9. Promoting a Healthy Lifestyle: Dangers of Indoor Tanning
- During the skin examination you have the opportunity to educate young people about the dangers of excessive UV exposure from direct sun exposure or from indoor tanning such as a tanning bed, booth, or sunlamp. Although most individuals understand the risk of direct sun exposure, they often underestimate the dangers of indoor tanning. It is important to emphasize that a tan is the response of the body to injury.Indoor tanning exposes users to UV-A and UV-B rays, both of which damage the skin. Exposure to UV radiation from indoor tanning devices not only increases the risk of melanoma but also is associated with an increased risk of nonmelanoma skin cancer such as squamous cell and basal carcinomas. This risk is particularly dangerous for younger users; those who begin tanning before age 35 have a 75% higher risk of melanoma.8 Yet the most recent National Health Interview Survey8 reported that 32% of non-Hispanic White women ages 18 to 21 reported indoor tanning not just once but an average of 28 sessions in the prior year. Although women are more likely to use tanning beds, men are not far behind. Of note is that women who live in the Midwest and South were shown to be more likely to use indoor tanning beds. Laws restricting indoor tanning use continue to emerge, with some already in place in some states (e.g., California, Vermont), especially for minors under age 18 years. Both the International Agency for Research on Cancer (IARC) (http://www.iarc.fr/) and the U.S. Department of Health and Human Services (HHS) have declared UV radiation from the sun and from artificial sources to be carcinogenic. Recently the IARC moved tanning beds to its highest cancer-risk category alongside other cancer-causing agents such as asbestos and cigarettes. Further, one of Healthy People 2020 goals is to reduce the proportion of teens who report using any artificial sources of UV light for tanning to 14% and the overall proportion of adults age 18 and older to 13.7%. Yet despite these public health warnings and increasing evidence of the dangers of artificial UV radiation, millions of individuals continue to frequent tanning salons. The “tan tax,” a provision tucked within the Affordable Care Act to discourage the use of indoor tanning beds, was implemented in 2010. Similar to the idea behind taxing cigarettes or more recent attempts to tax sugar-containing beverages, it is hoped that the 10% tax on the use of UV indoor tanning beds decreases their use while raising dollars toward the cost of expanding health coverage.
hyperventilation, hypoventilation
3. Differentiate between the following three types of adventitious
lung sounds and explain their significance Table 18 - 6 (Crackles, Wheezes, Stridor).
4. Differentiate between chest configurations (Barrel, Pectus Excavatum,
Pectus Carinatum, Scoliosis, and Kyphosis)
5. Differentiate between abnormal respiratory conditions and identify
assessment technique findings for each (Atelectasis, COPD, Acute Bronchitis, and Asthma, Tuberculosis, lung cancer)