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Nursing Fundamentals > Skin, Hair, Nails and HEENT: 6 Questions > Flashcards

Skin, Hair, Nails and HEENT: 6 Questions Flashcards

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1
Q

What is the Integumentary System?

A

Skin, Hair, Nails, Scalp

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2
Q

Palpation includes ?

A

Moisture, Texture, Turgor, and Temperature

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3
Q

Inspection includes?

A

Visible Surface first
Less visible surfaces as you examine each body system

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4
Q

Cyanosis is what?

A

(Blue Lips) which means low oxygen , nail beds, palpebral conjunctiva, palms

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5
Q

Pallor is what?

A

Paleness, buccal mucosa, conjunctiva, nail beds

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6
Q

What is Vitiligo?

A

Face, Hands, arms

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7
Q

What is Jaundice?

A

Yellow -Orange, sclera, mucous membranes, skin

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8
Q

What is Erythema?

A

Red, common in areas of pressure, but can be anywhere.

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9
Q

What is Vascularity?

A

Localized reddened, pink, or pale skin.

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10
Q

What is Petechiae?

A

Nonblanching, pinpoint-size, red or purple spot

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11
Q

What is normal skin moisture?

A

Smooth and dry with moist skin folds (such in the axillae

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12
Q

What is excessive perspiration?

A

Activity, warm environment, obesity, anxiety, excitement.

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13
Q

What is excessively dry?

A

Dullness, dryness, crusting, and flaking
Common in older adults, lack of humility, sun exposure, smoking, dehydration.

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14
Q

How do you get skin temperature?

A

Palpate the skin bilaterally with the Dorso side of the hand.

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15
Q

How do you assess skin texture?

A

Lightly palpate skin by using fingertips.

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16
Q

What is skin Turgor?

A

Skin elasticiity

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17
Q

Where do you assess skin turgor?

A

Grasp a fold of skin on the back of the forearm or sternum with the fingertips
DO NOT CHECK ON THE BACK OF HANDS

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18
Q

What is good turgor ?

A

Skin immediately falls back into place

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19
Q

What is poor turgor?

A

skin stays pinched (Tenting)=Dehydration

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20
Q

How to inspect Edema ?

A

Location
Color
Shape

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21
Q

How to palpate Edema ?

A

Mobility
Consistency
Tenderness

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22
Q

What do you not forget while assessing for edema?

A

Don’t forget to assess the Backside

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23
Q

What is the Braden Scale Assessment ?

A

Helps determine a patients risk for skin breakdown

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24
Q

What is stage 1 pressure injury?

A

Localized “Red” not blanched

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25
What is stage 2 pressure injury?
Exposed dermis, skin missing
26
What is stage 3 pressure injury?
Full thickness skin loss, adipose tissue
27
What is stage 4 pressure injury?
Skin, tissue, muscle, bone, and cartilage loss becomes exposed
28
What is a deep tissue injury?
Deep Maroon/Purple discoloration, Dark wound bed, blood=blister
29
What is unstageable?
Covered by stuff
30
What are lesions ?
Any unusual finding of the skin
31
What are the ABCDE of Skin Malignancies?
Asymmetry Border irregularity Color Diameter Evolution
32
What are Nits?
White, yellow, or tan "dots" eggs attached on hair shaft.
33
What is Lice?
White/grayish bodies
34
What are crabs?
Red Legs
35
How should nails be assessed?
Inspect and Palpate
36
What degree do you assess nail beds?
160 degrees
37
What color are nail beds dark skin patients?
Pink with white nail tips
38
What color are nail beds for lighter skin patients?
Darkly pigmented, blue or reddish hue
39
How should you assess the change in the nail angle?
Between the base and the nail is 180 degrees or more
40
What is nail clubbing ?
Enlarged fingertips and nail flattening
41
What does nail clubbing indicate ?
COPD
42
Opaque-yellow brittle dull, or thick nails indicates ?
Insufficient Calcium
43
Where should you look for Pallor ?
In the lower palpebral conjunctiva and tongue
44
How do you assess the Head and Skull?
Inspection and Palpation
45
What three things do you assess for the Head/Skull?
Position (head should be upright and midline to the trunk. Size (should not appear unusually large or small) Shape and Contour (Skull round with prominences in the frontal and occipital areas. No nodules or masses.
46
How to assess for facial features?
Inspection
47
What do you inspect the face for ?
Shape and Symmetry
48
What are the Head, Skull, Facial Features abnormal findings?
Tremors, hearing loss, Acromegaly
49
Are Eyes External or Internal structures?
External Structures
50
How do assess the eyes?
Inspection and some palpation-clean gloves
51
How many times do you blink a minute?
20 times per min
52
How do you position the eyes?
Parallel....no bulging (exophthalmos), protrusion, or crossed eyes (strabismus)
53
What tool do you use for eye exam?
Penlight
54
How many directions do you gaze ?
6 directions
55
What type of movements do your eyes do for the exam ?
Extra-ocular Movements
56
What is Nystagmus?
Abnormal Gaze far left or right
57
What test is for distant vision?
Snellen Chart
58
How far do you stand from the Snellen Chart ?
20 feet Read each line with each eye Note smallest eye accurately
59
What test do you for Near Vision?
Read aloud a handheld/printed material.
60
What are the ears?
Auricles
61
How do assess the ears ?
Inspection (size, shape, symmetry, landmarks, position, color, discharge)
62
What are the normal ears?
Equal size/level, vertical, top even with outer canthus of eye, same color as face, yellow cerumen (Earwax)
63
What tool do you use for Inspection of the ears?
Otoscope
64
What do you inspect in the ears?
Tympanic Membrane
65
What is the Rinne Test?
Single and Behind the ear. Mastoid Process and patients response to hear.
66
What is the Weber Test?
Midline patients top of the forehead, can the patient hear the sound equally?
67
What is the Whisper Test?
Random numbers/equal syllables, each ear, one at a time while patient occludes the other ear.
68
How do assess the nose ?
Inspection and Palpation
69
External Nose ?
Shape, size, skin color, any deformity or inflammation. Palpate ridge and soft tissue for tenderness, masses, deviations.
70
Patency of Nares
Occlude one naris and have patient breathe with closed mouth. Repeat with other naris.
71
What is Sinus tenderness?
Palpate with thumbs using gentle upward pressure over the frontal sinuses, under the eyebrows, and over the maxillary sinuses.
72
What equipment is used for Mouth and Pharynx inspection?
Clean gloves, tongue depressor, gauze, penlight
73
Lips Inspection
color, texture, hydration, contour, lesions * View with mouth closed
74
Teeth Inspection
symmetry of smile, color of teeth, presence of caries, tartar, extraction sites * Have clench teeth and smile, then open mouth
75
Mucosa/Buccal Mucosa
color, hydration, texture, lesions * Open mouth, retract lips away from teeth, retract cheeks with tongue depressor, illuminate w/penlight
76
Gums Inspection
color, edema, retraction, bleeding, lesions * Inspect while cheeks retracted with tongue depressor
77
Tongue and Floor of Mouth
movement, color, position, texture, coatings, lesions * Have stick out tongue halfway, raise tongue and move side to side, lift tongue and place tip on palate * Illuminate with penlight and inspect all surfaces and underside
78
Hard and Soft Palates
Color, shape, texture, extra bony prominences or defects * Have tilt head backward/hold mouth open. Inspect roof of mouth.
79
Pharynx
color and texture. edema, petechiae, lesions, exudate? * Have tilt head back slightly and say “ah”, place tip of depressor on middle third of tongue.
80
How do you assess the neck?
Inspection and Palpationlocation, size, consistency, mobility, tenderness, warmth
81
Neck has what?
Lymph Nodes
82
NECK MUSCLES
Sternocleidomastoid and trapezius muscles Inspect symmetry of neck muscles, range of motion, any discomfort
83
TRACHEA
normally located midline above suprasternal notch
84
THYROID GLAND
fixed to trachea w/ isthmus at midline, two cone-shaped lobes at each side.
85
Labs
* CBC * Nasal swab (Covid, flu) * Culture * Throat swab (strep)
86
MEDICATIONS
Eye drops/ointments * Nasal spray * Ear drops * Oral medications * Topical medications

Nursing Fundamentals (10 decks)

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