Ch. 8,9,12,13- Assessment Techniques, General Surgery, Nutrition Assessment, Skin, Hair, and Nails

Question 1

In most cases perform assessment techniques in what order?

Answer 1

• Inspection
• Palpation
• Percussion
• Auscultation

Question 2

What are you assessing when using palpation?

Answer 2

• texture/temp/moisture (use back of hands)
• swelling
• pulsations
• organ location/size
• muscle rigidity/spasticity
• crepitus (“rice Krispy sensation”)
• lumps/masses
• tenderness/pain

Question 3

What is percussion?

Answer 3

Tapping person’s skin with short, sharp strokes to assess underlying structures

Question 4

Percussion has what uses?

Answer 4

• Mapping location and size of organs

- Signaling density or a structure by a characteristic note

Question 5

When using percussion, a structure with more air produces what sounds?

Answer 5

louder, deeper compared with denser structures

Question 6

When using percussion only what should be touching the patient s skin?

Answer 6

distal joint and tip of middle finger

Question 7

Explain the quality and location of a resonant percussion note?

Answer 7

amp: medium/loud
pitch: low
quality: clear/ hollow
duration: moderate
sample location: over normal lung tissue

Question 8

Explain the quality and location of a tympany percussion note?

Answer 8

amp: loud
pitch: high
quality: musical and drum like
duration: sustained longest
sample location: over air-filled viscous (ex: stomach, intestines)

Question 9

Explain the quality and location of a dull percussion note?

Answer 9

amp: soft
pitch: high
quality: muffled thud
duration: short
sample location: relatively dense organ as liver or spleen

Question 10

The diaphragm of a stethoscope is what?

Answer 10

Flat edge, for high-pitched sounds

Question 11

The bell of a stethoscope is what?

Answer 11

Deep, hollow, cuplike, for low pitched sounds

Question 12

The general survey is a study of the whole person which includes what?

Answer 12

-Overall immediate impression of a person

including physical appearance, body structure, mobility, behavior

Question 13

What objective data do we include when assessing a persons physical appearance?

Answer 13

• Age
• LOC/orientation
• Skin color
• Facial features
• Overall appearance

Question 14

What objective data do we include when assessing a persons body structure?

Answer 14

• Stature
• Nutrition
• Symmetry
• Posture
• Position
• Physical deformities

Question 15

What objective data do we include when assessing a persons mobility?

Answer 15

• Gait
• Extremity movement
• ROM

Question 16

What objective data do we include when assessing a persons behavior?

Answer 16

• Facial expression
• Mood and affect
• Speech
• Dress
• Personal hygeine

Question 17

What things should be done when obtaining weights?

Answer 17

• Aim for same time of day
• trend weights/ observe changes
• outpatient= remove shoes and heavy outer clothing

Question 18

What things should be done when obtaining heights?

Answer 18

• use wall-mounted/pole on scale devices

- pt. shoed be shoeless, standing straight, looking straight ahead

Question 19

What is BMI?

Answer 19

-Practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

Question 20

The aging adult typically has what physical appearances?

Answer 20

• sharper body contour
• more angular facial features
• subcutaneous fat lost from face and periphery

Question 21

The aging adult typically has what posture characteristics?

Answer 21

forward flexion occurs by eighth or ninth decade

Question 22

The aging adult typically has what type of gait?

Answer 22

• wider base to compensate for diminished balance

- steps may be shorter or uneven

Question 23

Adult emergence of metabolic syndrome is a concern leading to what risk?

Answer 23

increased cardiac risk

Question 24

What is sarcopenia?

Answer 24

age-related loss of muscle mass

Question 25

What is sarcopenia obesity?

Answer 25

low muscle mass with excess fat

Question 26

Who are at increased risk to develop undernutrition or over nutrition?

Answer 26

people as they age

Question 27

What are major risk factors for malnutrition in older adults?

Answer 27

- poor physical or mental health - social isolation - alcoholism - limited functional ability - poverty - polypharmacy

Question 28

What are the purposes of nutritional assessment?

Answer 28

- identify individuals who are malnourished or a at risk of developing malnutrition - provide data for designing a nutrition plan of care - various data collection methods

Question 29

What are types of nutritional objective data?

Answer 29

- Observation of general appearance - Height - Weight - BMI

Question 30

What are other areas to asses during a skin inspection?

Answer 30

- under large breasts - obese abdomen - groin

Question 31

What areas should always be assessed for skin breakdown?

Answer 31

Pressure points and folds

Question 32

What objective data is collected when assessing skin color?

Answer 32

- General pigmentation, freckles, moles, birthmarks | - widespread color change

Question 33

What objective data is collected when assessing skin temperature?

Answer 33

- Use back of hands to palpate person - skin should be warm, and temp equal bilaterally - hands and feet may be slightly cooler in a cool environment

Question 34

What objective data is collected when assessing skin moisture?

Answer 34

- Diaphoresis | - Dehydration

Question 35

What other objective data is collected when assessing skin?

Answer 35

- Texture/thickness - edema - mobility and turgor (use fold under clavicle) - vascularity and bruising

Question 36

What are compound nevus?

Answer 36

macular and papular. | intradermal nevus has nevus cells in only the dermis

Question 37

What is Vitiligo?

Answer 37

acquired condition: complete absence of melanin pigmentation in patchy areas white or light skin on the face, neck, hands, feet, and body folds around orifices

Question 38

What are vascular lesions?

Answer 38

Vascular lesions are relatively common abnormalities of the skin and underlying tissues, more commonly known as birthmarks. There are three major categories of vascular lesions: Hemangiomas, Vascular Malformations, and Pyogenic Granulomas.

Question 39

If any lesions are present, note what objective data?

Answer 39

- Color - Elevation - Pattern or shape - Size - Location and distribution on body - Any exudate (drainage): note color and odor

Question 40

Wat objective data should be noted when assessing nails?

Answer 40

- Shape and contour - Consistency - Color - CRT (normal is <3 seconds)

Question 41

What is clubbing?

Answer 41

Lost profile sign associated with chronic lung disease.

Question 42

What objective data should be recorded when assessing hair?

Answer 42

- Color - Texture - Distribution - Lesions

Question 43

What hair/skin/nails changes do we see in the aging adult?

Answer 43

- Elasticity lost, skin folds and sags - Sweat and sebaceous glands decrease, dry - Senile purpura (discoloration due to increasing capillary fragility)

Question 44

What is the ABCDEF skin assessment used for?

Answer 44

Teach skin self-examination to rule to detect suspicious lesions

Question 45

What is the ABCDEF skin assessment?

Answer 45

- A: Assymmetry - B: Border - C: Color - D: Diameter (>6mm is concerning) - E: Elevation - F: Ugly Duckling (does it stand out?)