Vascular Sounds, Abdominal,

The clinical treat handsts described and recommended in this publication atomic itemise 18 lowd on res headch and consultation with nursing, medical, and legal authorities. To the outdo of our noticeledge, these procedures formulate currently accepted practice. Neverthe slight, they ro consumptiont be trusted absolute and frequent recommendations. For individual applications, all recommendations must be con lieured in light of the enduring role role ofs clinical antecedent and, before administration of revolutionary or infrequently employd do drugss, in light of the latest package-insert information. The authors and publisher isclaim whatsoever responsibility for any(prenominal) adverse effects outgrowthing from the suggested procedures, from any undetected errors, or from the charterers misunders tanding of the text. 2011 by Lippincott Williams & Wilkins. all(prenominal) even offs reserved. This book is defend by copyright. No part of it uncloudedthorn be r eproduced, stored in a retrieval dodge, or transmitted, in any form or by any meanselectronic, mechanical, photocopy, geni victimisation, or some otherwisewithout prior create verbally liberty of the publisher, except for brief quotations embodied in critical articles and reviews and testing and valuation materials provided by publisher to instructors hose schools have adopted its accompanying textbook. Printed in China. For information, write Lippincott Williams & Wilkins, 323 Norristown Road, Suite 323, Ambler, PA 19002-2756. Derived from Ameri mass Gothic, 1930 by Grant Wood. All rights reserved by the estate of Nan Wood Graham/licensed by VAGA, New York, NY. The publishers have made every effort to detect permission from the copyright holders to use borrowed material. If any material requiring permission has been overlooked, the publishers give be pleased to make the necessary arrangements at the first opportunity. HAIV020410 subroutine library of Congress Cataloging-i n-Publication DataHealth judgment made incredibly ocular. 2nd ed. p. cm. ( implausibly visual) Includes bibliographic references and index. ISBN 978-1-60547-973-6 (alk. paper) 1. bodily diagnosisAtlases. 2. physiological diagnosisHandbooks, manuals, etc. I. Series fabulously visual. DNLM 1. breast feeding discernmentmethods Atlases. 2. Nursing discernmentmethods Handbooks. 3. Physical Examination methodsAtlases. 4. Physical Examination methodsHandbooks. WY 49 H434 2011 RT48. H448 2011 616. 0754dc22 ISBN13 978-1-60547-973-6 ISBN10 1-60547-973-X (alk. paper) 2009049443 Staff Publisher Chris Burg tryingt Clinical chooseor Joan M. Robinson, RN, MSNProduct motorbus Diane Labus Clinical Project Manager Beverly Ann Tscheschlog, RN, MS editor program Jaime Stockslager Buss, MSPH, ELS Copy Editor K atomic number 18n Comerford Design Coordinator Joan Wendt Illustrator Bot Roda Associate Manufacturing Manager Beth J. Welsh Editorial Assistants Kargonn J. Kirk, Jeri OShea, Linda K. Ruhf Contents coarse chord A work of art iv Contri just nowors and consultants vi 1 fundamental principle 1 2 Skin, tomentum, and completes 11 3 sums and stiletto heels 27 4 Nose, mouth, throat, and neck 49 5 Respiratory trunk 67 6 Cardiovascular transcription 87 7 Breasts and axillae 113 8 GI system 127 9 Musculoskeletal system 147 10 Neurologic system 171 1 Genitourinary system 193 Selected references 239 Credits 240 Index 242 12 Pregnancy 213 iv Contributors and consultants Im so excited to be here right away The gallery is opening its new exhibit, Health Assessment Made Incredibly Visual. ruff picture outside(a) the average output note I h spike heel its a masterpiece thats guaranteed to inspire top-notch surveyment skills. Its even more(prenominal) extraordinary than I expected. outside the norm take note v The vividly detailed illustrations and photographs of super commonplace findings are definitely Outside the norm. And what chiaroscuro And Im certainly go ing to germinate note of this piece. You an rank that it captures lifelike charts that illustrate the correct ways to enumeration valuatement findings. If this collection were a movie, it would have Best picture written all over it. The graphic depictions of best judgement practices that appear passim are unique and innovative. All-in-all, I find this a visually immobilise and exciting new work. It has certainly inspired me to master health assessment. best picture vi Contributors and consultants Nancy Berger, RN, MSN, BC, CNE Program Coordinator placesex County College Edison, N. J. Marsha L. Conroy, RN, BA, MSN, APN Nurse Educator Indiana Wesleyan University MarionChamberlain College of Nursing Columbus, Ohio Roseanne Hanlon Rafter, RN, MSN, GCNS, BC Director of Nursing Professional Practice chromatic Hill Hospital Philadelphia, Pa. Dana Reeves, RN, MSN Assistant prof University of ArkansasFort metalworker Denise Stefancyk, RN, BSN, CCRC Clinical Specialist University o f Massachusetts Medical Center Worcester Allison J. Terry, RN, PhD Director, Center for Nursing Alabama Board of Nursing Montgomery Leigh Ann Trujillo, RN, BSN Clinical Educator St. crowd together Hospital and Health Centers Olympia Fields, Ill. Rita M. Wick, RN, BSN Simulation Coordinator Berkshire Health Systems Pittsfield, Mass.Sharon E. Wing, RN, PhD(C), CNL Associate Professor Cleveland (Ohio) State University Lisa Wolf, RN, MS, CMSRN Clinical Educator Mount C artilleryel West Columbus, Ohio Health storey 2 Physical assessment 6 Documentation 9 sight quest 10 Ready. Action Health explanation Interviewing tips To make the closely of your uncomplaining interview, create an environment in which the tolerant feels comfortable. Also, use the succeeding(a) techniques to ensure impelling communication. basics deliverd by the long-suffering, or subject corroborate only by the patient Include statements such(prenominal)(prenominal) as My result hurts or I have trouble s leeping Subjective entropy Are observed Are verifiable Include findings such as a red, swollen arm in a patient with arm pain Objective data The success of your patient interview depends on effective communication. Select a quiet, private setting. Choose wrong guardedly and avoid using medical jargon. Speak late and clearly. white plague effective communication techniques, such as silence, facilitation, con self-coloredation, reflection, and clarification. utilisation open-ended and closed-ended questions as distinguish. Use appropriate frame language. Confirm patient statements to avoid misunder patronageing. Summarize and pause with Is there anything else? 2 Fundamentals All assessments involve collecting dickens kinds of data objective and subjective. The health invoice gathers subjective data well-nigh the patient. Health memorial 3 Comp atomic number 53nts of a complete health history Biographical data Name _________________________________________ _ Address ________________________________________ Date of birth ____________________________________ make headway mastermindive explained Yes No Living will on chart Yes No Name and phone numbers of next of kin NAME affinity PHONE ________________________________________________ ________________________________________________Chief complaint History of present illness ________________________________________________ ________________________________________________ on-line(prenominal) medications dose AND DOSE FREQUENCY LAST DOSE ________________________________________________ ________________________________________________ Medical history Allergies videotapeline Iodine Latex No known allergies Drug _________________________________________ Food _________________________________________ environmental _________________________________ Blood reaction _________________________________ Other _________________________________________ Childhood illnessesDATE _______ _________________________________________ ________________________________________________ Previous hospitalizations (Illness, accident or injury, surgery, blood transfusion) DATE Health problems Yes No Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blood problem (anemia, reap hook cubicle, clotting, bleeding). . . . johncer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . Eye problem (cataracts, glaucoma) . . . . . . . . . . . . Heart disease ( intent failure, MI, valve disease) Hiatal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . human immunodeficiency virus/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney problem . . . . . . . . . . . . . . . . . . . . . . . . . Liver problem . . . . . . . . . . . . . . . . . . . . . . . . . . . Lung problem (asthma, bronchitis, emphys ema, pneumonia, TB, precipitousness of breath) . . . . . . . . . . . . cerebrovascular accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thyroid problem . . . . . . . . . . . . . . . . . . . . . . . . . ulcers (duodenal, peptic). . . . . . . . . . . . . . . . . . . . Psychological disorder . . . . . . . . . . . . . . . . . . . Obstetric history (females) Last menstrual period _____________________________ Gravida __________ Para ___________ Menopause Yes No Psychosocial history Coping strategies _________________________________________________ Feelings of safeguard ________________________________________________ Social history Smoker No Yes ( packs/ mean solar day _____ years ___ ) Alcohol No Yes (type ________ standard/day ___ ) Illicit drug use No Yes (type ____________ ) Religious and cultural observances ________________________________________________ Activities of daily living pabulum and exercise regimen _________________________Elimination pa tterns _______________________________ Sleep patterns ____________________________________ Work and leisure activities _________________________ Use of safety vizors (seat belt, bike helmet, sunscreen) ______________________ Health maintenance history DATE Colonoscopy ____________________________________ Dental examen _______________________________ Eye examination _________________________________ Immunizations ___________________________________ Mammography __________________________________ Family medical history Health problem Yes No Who (parent, grandparent, sibling) demand around the patients family edical history, including history of diabetes or heart disease. call for active the patients feelings of safety to help secern physical, psychological, emotional, and sexual abuse issues. Arthritis . . . . . . . . . . . . Cancer . . . . . . . . . . . . . Diabetes mellitus . . . . . Heart disease (heart failure, MI, valve disease) . . Hypertension . . . . . . . . Stroke . . . . . . . . . . . . . Be sure to admit prescription drugs, over-the-counter drugs, herbal preparations, and vitamins and supplements. 4 Fundamentals During the final part of the health history, ask a passage of arms from each one consistency structure and system to make sure that important ymptoms werent missed. Start at the top of the head and work your way consume to the toes. Head Psychological status Neck Endocrine system Breasts and axillae Gastrointestinal system Reproductive system habitual health Neurologic system Eyes, ears, and nose Mouth and throat Skin, hair, and nails Cardiovascular system Respiratory system Hematologic system Urinary system Musculoskeletal system criticism of structures and systems Health history 5 Evaluating a symptom Perform a foc employ physical examination to quickly come across the severity of the patients condition. Take a thorough history. take down GI disorders that endure lead to abdominal distention.Thoroughly examine the patient. Obs erve for abdominal asymmetry. Inspect the bark, picture for bowel sounds, percuss and palpate the abdomen, and measure abdominal girth. My stomach gets bloated. Your patient is vague in describing his chief complaint. employ your interviewing skills, you discover his problem is link to abdominal distention. Now what? This flowchart will walk you through what to do next. Take a brief history. Intervene appropriately to stabilize the patient, and apprise the doctor immediately. Review your findings to consider possible causes, such as dealcer, bladder distention, cirrhosis, heart failure, and astric dilation. After the patients condition stabilizes, review your findings to consider possible causes, such as trauma, large-bowel obstruction, mesenteric artery occlusion, and peritonitis. Devise an appropriate care plan. Position the patient comfortably, administer ordered analgesics, and prepare the patient for diagnostic tests. Form a first impression. Does the patients condition alert you to an emergency? For example, does he say the bloating developed suddenly? Does he mention that other signs or symptoms bechance with it, such as sudor and light-headedness? (Indicators of hypovolemia) Yes NoAsk the patient to identify the symptom thats bothering him. Do you have any other signs or symptoms? Evaluate your findings. Are emergency signs or symptoms present, such as abdominal rigidity and ab usual bowel sounds? Yes No 6 Fundamentals Physical assessment Cotton balls Gloves Metric ruler (clear) Near- fancy and visual acuity charts Ophthalmoscope Otoscope Penlight Percussion hammer Paper clip weighing machine with height measurement Skin calipers Specula (nasal and vaginal) Sphygmomanometer Stethoscope Tape measure (cloth or paper) Thermometer correct fork Wooden tongue leaf blade Assessment toolsAssemble the necessary tools for the physical assessment. Then perform a general survey to form your sign impression of the patient. Obtain bas eline data, including height, weight, and alert signs. This information will direct the rest of your assessment. Measuring blood atmospheric pressure Position your patient with his focal ratio arm at heart level and his palm turned up. harbour the cuff snugly, 1 (2. 5 cm) above the brachial pulse. Position the manometer at your fondness level. Palpate the brachial or radial pulse with your hitchtips time inflating the cuff. Inflate the cuff to 30 mm Hg above the mastermind where the pulse disappears. Place the doorbell of your stethoscope over the point where you felt the pulse, as shown in the photo. (Using the bell will help you better hear Korotkoffs sounds, which indicate pulse. ) Release the valve slowly and note the point at which Korotkoffs sounds reappear. The start of the pulse sound indicates the systolic pressure. The sounds will become hushed and so disappear. The last Korotkoffs sound you hear is the diastolic pressure. best picture Got your tools? Goo d. Lets get to work Tips for interpreting vital signs Analyze vital signs at the same time. Two or more ab commonplace values whitethorn provide clues to the patients problem.For example, a rapid, th get hold ofy pulse along with low blood pressure may signal shock. If you obtain an abnormal value, take the vital sign once again to make sure its accurate. Remember that normal readings vary with the patients age. For example, temperature decreases with age, and respiratory rate can increase with age. Remember that an abnormal value for one patient may be a normal value for another, which is why baseline values are so important. Physical assessment 7 Physical assessment techniques When you perform the physical assessment, youll use four techniques audition, palpation, percussion section, and auscultation.Use these techniques in this range except when you perform an abdominal assessment. Because palpation and percussion can alter bowel sounds, the sequence for assessing the ab domen is inspection, auscultation, percussion, and palpation. 1 Inspection Inspect each torso system using vision, smell, and hearing to assess normal conditions and deviations. Observe for glossiness, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system. 2palpation Palpation requires you to touch the patient with different parts of your hands, using change degrees of pressure. Because your hands are your tools, keep your fingernails hort and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body swimmings. Palpate tender areas last. Types of palpation featherbrained palpation Use this technique to feel for surface abnormalities. Depress the shinny 1/2 to 3/4 (1. 5 to 2 cm) with your finger pads, using the lightest touch possible. Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial electric organs, and masses. Deep palpation Use this technique to feel in side organs and masses for size, shape, tenderness, symmetry, and mobility. Depress the disrobe 11/2 to 2 (4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure, if needed. 8 Fundamentals 3Percussion Percussion involves tapping your fingers or hands quickly and sharply against parts of the patients body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with bland or gas. 4Auscultation Auscultation involves listening for various breath, heart, and bowel sounds with a stethoscope. Types of percussion Direct percussion This technique reveals tenderness its commonly use to assess an adult patients sinuses. Heres how to do it Using one or two fingers, tap irectly on the body part. Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort. Indirect percussion This technique elicits sounds that give clues to the makeup of the underlying tiss ue. Heres how to do it Press the distal part of the essence finger of your non dominant hand severely on the body part. watch over the rest of your hand off the body surface. Flex the wrist of your dominant hand. Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patients scrape up. Listen to the sounds produced. Getting ready Provide a quiet environment. Make sure the area to be examined is receptive. ( Auscultating over a gown or bed linens can interfere with sounds. ) nimble the stethoscope head in your hand. Close your eyes to help snap your attention. How to auscultate Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patients fur, enough to leave a slight ring on the genuflect afterward. Use the bell to pick up low-spirited sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell softly against the patients peel, just enough to form a seal.Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low-pitched sounds. Listen to and try to identify the characteristics of one sound at a time. Documentation 9 Documentation Get to know your stethoscope Your stethoscope should have snug-fitting ear tips, which youll position toward your nose. The stethoscope should also have tubing no longer than 15 (38. 1 cm) with an internal diameter not greater than 1/8 (0. 3 cm). It should have both a dia phragm and bell. The parts of a stethoscope are labeled below. Ear tips Binaurals (ear resistances) Tension bar Tubing Bell bag Diaphragm Headset ChestpieceDocumenting initial assessment findings Heres an example of how to record your findings on an initial assessment form. take note Name duration _______ Sex ______ Height ________ Weight ________ T ______ P ___ R ___ B/P (R) ____________ (L) _____________ Room _____________________ Admission time ____________ Admission date ____________ secure ____________________ Admitting diagnosis ___________________________ ___________________________ ___________________________ ___________________________ Patients stated reason for hospitalization ______________ ___________________________ ___________________________ Allergies ___________________ __________________________ ___________________________ Current medications ________ Name Dosage Last taken _______________________________ _______________________________ _______________________________ _______________________________ General survey _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ atomic number 1 Gibson 55 M 163 cm 57 kg 37 C 76 14 150/90 sit 148/88 sitting 328 0800 4 -28-10 Manzel Pneumonia To get rid of the pneumonia PenicillinCodeine None In no swell distress. Slender, alert, and well-groomed. Communicates well. Makes eye contact and expresses appropriate concern throughout exam. C. Smith, RN General information Identify the assessment technique being used in each illustration. Show and tell Unscramble the words at right to discover terms related to fundamentals of assess ment. Then use the circled letters from those words to answer the question posed. My word Answers Show and tell 1. Indirect percussion, 2. Deep palpation My word 1. Auscultation, 2. Subjective data, 3. Chief complaint, 4. Palpation straits Abdomen 10 1. 2. 1. tunicaastolu 2. ivateacub jest 3. place inchmotif 4. aplaintop Answer Question Assessment of which body part does not follow the usual sequence? embodiment 12 Assessment 14 Skin abnormalities 16 haircloth abnormalities 24 dash abnormalities 25 Vision quest 26 soothe on the set. The assessment is slightly to begin. Anatomy 12 Skin, hair, and nails SkinSkin, hair, nails The skin covers and treasures the internal structures of the body. It consists of two distinct social classs the epidermis and the dermis. Subcutaneous tissue lies beneath these layers. cuticle Outer layer Made of squamous epithelial tissue Dermis Thick, deeper layer Consists of assignive issue and an extra jail cellular material ( ground substance), which contributes to the skins intensiveness and pliability Location of blood vessels, lymphatic vessels, nerves, hair follicles, and sweat and sebaceous glands Subcutaneous tissue Beneath dermis and epidermis Consists in the main of fatty and other connective tissues Stratum corneum Pore of sweat gland Free nerve ending Eccrine sweat gland pilus bulb sensational nerve fibers Autonomic nerve fibers Artery vein Anatomy 13 Hair Hair is formed from keratin produced by matrix cells in the dermal layer of the skin. Each hair lies in a hair follicle. Hair shaft Sebaceous gland Arrector pili brawninessHair follicle Sensory nerve fibers Hair bulb Contains melanocytes Hair papilla Consists of a loop of capillaries Provides provisions to hair Nails Nails are formed when epidermal cells are converted into hard plates of keratin. Hyponychium Nail plate Lateral nail fold Lunula Eponychium Nail resolution Nail matrix Hair bulb Matrix cell Produces hair Cuticle cells Inner root sheath Outer root sheath Capillary in hair papilla Melanocyte Determines hair coloring What is the matrix? The area of the dermis on which the nail rests. 14 Skin, hair, and nails Assessment To assess the skin, hair, and nails, use inspection and palpation. SkinObserve the skins overall appearance. Then inspect and palpate the skin area by area, focusing on color, moisture, texture, turgor, and temperature. assure the conjunctivae, palms, soles, buccal mucosa, and tongue. Look for dull, dark color. Examine the area for decreased color and palpate for tightness. Palpate the area for warmth. Examine the sclerae and hard palate in natural, not fluoresce nt, light if possible. Look for a yellow color. Examine the sclerae, conjunctivae, buccal mucosa, lips, tongue, nail beds, palms, and soles. Look for an ashen color. Examine areas of lighter pigmentation such as the abdomen. Look for tiny, purplish red ots. Palpate the area for skin texture changes. Cyanosis Edema Erythema Jaundice Pallor Petechiae Rashes Color Look for localized areas of bruising, cyanosis, pallor, and erythema. micro chip for uniformity of color and hypopigmented or hyperpigmented areas. Moisture Observe the skins moisture content. The skin should be relatively dry, with a minimal amount of perspiration. Be sure to enter gloves during your examination of the skin, hair, and nails. Detecting color variations in dark-skinned plurality Assessment 15 Texture and turgor Inspect and palpate the skins texture, noting its thickness and mobility. It should look smooth and be intact.To assess skin turgor in an infant, grasp a fold of loosely follower abdominal skin betw een your thumb and forefinger and pull the skin taut. Then release the skin. The skin should quickly return to its normal position. If the skin remains tented, the infant has curt turgor. Temperature Palpate the skin bilaterally for temperature using the dorsal surface of your hands and fingers. The dorsal surface is the most mass medium to temperature changes. Warm skin suggests normal circulation cool skin, a possible underlying disorder. Assessing skin turgor in an adult Gently squeeze the skin on the forearm or sternal rea between your thumb and forefinger, as shown. If the skin quickly returns to its original shape, the patient has normal turgor. If it returns to its original shape slowly over 30 seconds or entertains a tented position, as shown, the skin has poor turgor. best picture Normal skin variations You may see normal variations in the skins texture and pigmentation. Such variations may include nevi, or bulwarks, and freckles (shown below). 16 Skin, hair, and nails L esion configurations Discrete Individual lesions are separate and distinct. class Lesions are clustered together. Dermatomal Lesions form a line or an loathly and follow dermatome. Confluent Lesions merge so that discrete lesions are not visible or palpable. Lesion shapes Discoid Round or oval ringed Circular with primal clearing Target (bulls eye) Annular with central internal activity Hair When assessing the hair, note the distribution, quantity, texture, and color. Hair should be every bit distributed. Nails Examine the nails for color, shape, thickness, consistency, and contour. Nail color is pink in light-skinned people and dark-brown in dark-skinned people. The nail surface should be roughly curved or flat and the edges smooth and rounded. Lesions When evaluating a lesion, youll need to dissever t as primary (new) or secondary (a change in a primary lesion). Then determine if its solid or fluid-filled and describe its characteristics, pattern, location, and distributio n. Include a description of symmetry, borders, color, configuration, diameter, and drainage. Skin abnormalities I know youll have these assessment skills nailed in no time Lesion distribution generalize Distributed all over the body Regionalized particular(a) to one area of the body Localized Sharply limited to a specific area at sea Dispersed either densely or widely Exposed areas Limited to areas exposed to the air or sun Intertriginous Limited to reas where skin comes in contact with itself Skin abnormalities 17 outside the norm Types of skin lesions tornado A painful, cracklike lesion of the skin that extends at least into the dermis Cyst A closed sac in or under the skin that contains fluid or semisolid material Papule A solid, increase lesion thats unremarkably less(prenominal) than 1 cm in diameter Vesicle A small, fluid-filled blister thats unremarkably 1 cm or less in diameter Bulla A large, fluid-filled blister thats usually 1 cm or more in diameter Ulcer A cr aterlike lesion of the skin that usually extends at least into the dermis macular area A small, discolored spot or patch on the skinWheal A raised, chromatic area thats commonly itchy and lasts 24 hours or less Pustule A small, pus-filled lesion (called a follicular pustule if it contains a hair) Nodule A raised lesion detectable by touch thats usually 1 cm or more in diameter Documenting a skin lesion take note At 0820, pt. c/o right shoulder blade pain, 4/10 on a 0-10 scale. A closed, purulent lesion noted in right upper scapular region of back, approx. 1. 5 cm x 1 cm, with 3 cm surrounding area of erythema. T 100. 2 F. Call placed to Dr. Tomlins service at 0830. Angela Kessler, RN 4/15/10 0845 18 Skin, hair, and nails Benign versus malignant lesionsLesions may be benign, such as a benign nevus, or mole. However, changes in an existing growth on the skin or a new growth that ulcerates or doesnt heal could indicate cancer or a precancerous lesion. Types of skin cancer outside t he norm perverted changes in keratinocytes Can become squamous cell carcinoma Precancerous actinic keratosis deviant growth of melanocytes in a mole Can become malignant melanoma Dysplastic nevus Note the differences between benign and cancerous lesions. Symmetrical, round, or oval shape Sharply defined borders Uniform, usually tan or brown color Less than 6 mm in diameter Flat or raisedBenign nevus Abnormal changes in keratinocytes Can become squamous cell carcinoma Abnormal growth of melanocytes in a mole Can become malignant melanoma Skin abnormalities 19 more(prenominal) severe Less severe Begins as a firm, red tubercle or scaly, crusted, flat lesion Can sprinkle if not treated Squamous cell carcinoma Most common skin cancer normally spreads only locally Basal cell carcinoma Can arise on normal skin or from an existing mole If not treated promptly, can spread to other areas of skin, lymph nodes, or internal organs Malignant melanoma If you fishy a lesion may be malignant melanoma, observe for these haracteristics. memory lineup ABCDEs of malignant melanoma A = Asymmetrical lesion B = Border unpredictable C = Color of lesion varies with shades of tan, brown, or black and, possibly, red, blue, or white D = Diameter greater than 6 mm E = rattling(a) or enlarging lesion 20 Skin, hair, and nails Common skin disorders outside the norm contact dermatitis is an inflammatory disorder that results from contact with an irritant. Primary lesions include vesicles, large guck bullae, and red macules that appear at localized areas of redness. These lesions may itch and burn. finish up dermatitis Psoriasis is a chronic disease of marked pidermal thickening. Plaques are symmetrical and broadly speaking appear as red bases topped with silvery scales. The lesions, which may connect with one another, occur most commonly on the scalp, elbows, and knees. Psoriasis Occurring as an supersensitised reaction, urticaria appears suddenly as pink, edem atous papules or wheals (round elevations of the skin). Itching is intense. The lesions may become large and contain vesicles. Urticaria (hives) Skin abnormalities 21 Mites, which can be picked up from an infested person, burrow under the skin and cause itch lesions. The lesions appear in a straight or zigzagging line about 3/8 (1 cm) ong with a black dot at the end. commonly seen between the fingers, at the bend of the elbow and knee, and around the groin, abdomen, or perineal area, scabies lesions itch and may cause a rash. Scabies herpes virus zoster appears as a group of vesicles or crusted lesions along a nerve root. The vesicles are usually unilateral and appear mostly on the trunk. These lesions cause pain but not a rash. herpes virus zoster Tinea corporis is characterized by round, red, scaly lesions that are accompanied by intense itching. These lesions have slightly raised, red borders consisting of tiny vesicles. Individual ring may connect to form atches with scalloped edges. They usually appear on exposed areas of the body. Tinea corporis (ringworm) Once I burrow under the skin, I settle down and make myself comfortable. 22 Skin, hair, and nails Pressure ulcers Pressure ulcers are localized areas of skin breakdown that occur as a result of prolonged pressure. Necrotic tissue develops because the vascular supply to the area is diminished. represent pressure ulcers You can use characteristics gained from your assessment to stage a pressure ulcer, as described here. Staging reflects the anatomic depth of exposed tissue. Keep in mind that if the irritate contains necrotic issue, you wont be able to determine the stage until you can see the wound base. outside the norm Suspected deep tissue injury Maroon or purple intact skin or blood-filled blister whitethorn be painful mushy, firm, or boggy and warmer or cold than other tissue before discoloration occurs Stage I whole skin that doesnt blanch whitethorn differ in color from surrounding area i n people with darkly pigmented skin Usually over a emaciated prominence May be painful, firm or soft, and warmer or cooler than surrounding tissue Note This stage shouldnt be used to describe perineal dermatitis, maceration, tape burns, skin tears, or excoriation.Stage II Superficial partial-thickness wound Presents as a shallow, open ulcer without slough and with a red and pink wound bed Skin abnormalities 23 Stage III Involves full-thickness wound with tissue loss and possibly visible subcutaneous tissue but no exposed heft, tendon, or bone May have slough but not enough to hide the depth of tissue loss May be accompanied by undermining and tunneling Stage IV Involves full-thickness skin loss, with exposed muscle, bone, and tendon May be accompanied by eschar, slough, undermining, and tunneling Unstageable Involves full-thickness tissue loss, with base of ulcer covered by slough nd yellow, tan, gray, green, or brown eschar Cant be staged until enough slough and eschar are removed to expose the wound base 24 Skin, hair, and nails Hair abnormalities typically stemming from other problems, hair abnormalities can cause patients emotional distress. Among the most common hair abnormalities are alopecia and hirsuteness. Alopecia occurs more commonly and extensively in men than in women. Diffuse hair loss, though commonly a normal part of aging, may occur as a result of pyrogenetic infections, chemical trauma, ingestion of certain drugs, and endocrinopathy and other disorders. Tinea capitis, trauma, and ull-thickness burns can cause patchy hair loss. Alopecia Excessive hairiness in women, or hirsutism, can develop on the body and face, affecting the patients selfimage. Localized hirsutism may occur on pigmented nevi. Generalized hirsutism can result from certain drug therapy or from such endocrinal problems as Cushings syndrome, polycystic ovary syndrome, and acromegaly. Hirsutism outside the norm Now hair this Hair abnormalities may be caused by cer tain drugs or endocrine problems. Nail abnormalities 25 Nail abnormalities Although many nail abnormalities are harmless, some point to serious underlying problems.Nail abnormalities include clubbed fingers, splinter hemorrhages of the nail bed, and Muehrckes lines. outside the norm Splinter hemorrhages are reddish brown pin down streaks under the nails. They run in the same direction as nail growth and are caused by minor trauma. They can also occur in patients with bacterial endocarditis. Splinter hemorrhages Muehrckes lines or leukonychia striata are longitudinal white lines that can indicate trauma but may also be associated with metabolic stress, which impairs the body from using protein. Muehrckes lines Clubbed fingers can result from chronic tissue hypoxia. Normally, the cant over between the ingernail and the point where the nail enters the skin is about one hundred sixty degrees. Clubbing occurs when that angle increases to 180 degrees or more. Clubbed fingers Normal fin gers Normal angle (160 degrees) Clubbed fingers Angle greater than 180 degrees Enlarged and curved nail Answers commensurate to label 1. Epidermis, 2. Dermis, 3. Subcutaneous tissue, 4. Hair bulb, 5. Eccrine sweat gland Rebus interpenetrate The dorsal surface of the hand is most sensitive to temperature changes. 1. 2. 3. 4. 5. Identify the skin structures indicated on this illustration. Sound out each group of pictures and symbols to reveal terms that complete this assessment onsideration. Able to label? Rebus riddle 26 Anatomy 28 Assessment 31 Eye abnormalities 42 Ear abnormalities 46 Vision quest 48 Aye, aye, matey I best be gettin along. Theyre filming the eye and ear assessment down on Soundstage 3. 28 Eyes and ears Anatomy EyeEsye and ears The eyes are delicate sensational organs equipped with many extraocular and intraocular structures. Some structures are easily visible, whereas others can only be viewed with special instruments, such as an ophthalmoscope. Extraocular stru ctures The bony orbits protect the eyes from trauma. The eyelids (or pal pebrae), lashes, and lacrimal gland, punctum, canaliculi, and ac protect the eyes from injury, dust, and contradictory bodies. Bony orbit Lacrimal gland Pars orbitalis Pars palpebralis Upper eyelid Lashes dismantle eyelid Lacrimal punctum Lacrimal canaliculi Lacrimal sac Nasolacrimal duct Eye muscles Superior oblique muscle Superior rectus muscle Medial rectus muscle Lateral rectus muscle Inferior rectus muscle Inferior oblique muscle Anatomy 29 Intraocular structures The intraocular structures of the eye are directly involved in vision. The eye has three layers of tissue The outermost layer includes the transparent cornea and the sclera, which maintain the form and size of the eyeball. The middle layer includes the choroid, ciliary body, and iris. Pupil size is controlled by involuntary muscles in this region. The internalmost layer is the retina, which receives visual stimuli and sends them to the brai n. retinene structures A closer view Superonasal arteriole and vein heart magnetic disk Physiologic cup Arteriole Inferonasal arteriole and vein Vein Superotemporal arteriole and vein Fovea centralis Macular area Inferotemporal arteriole and vein Sclera choroid coat Conjunctiva (bulbar) Ciliary body Cornea Lens Pupil Iris Anterior sleeping room (filled with aqueous humor) Posterior chamber (filled with aqueous humor) Schlemms canalVitreous humor Optic nerve Central retinal artery and vein Retina These structures are locate in the posterior part of the eye, also called the fundus. Theyre visible with an ophthalmoscope. 30 Eyes and ears Ear External ear The flexible external ear consists mainly of elastic cartilage. It contains the ear flap, also known as the auricle or pinna, and the auditory canal. This part of the ear collects and transmits sound to the middle ear. Middle ear The tympanic membrane separates the external and middle ear. The center, or umbo, is accustomed to the tip of the long process of the malleus on the other side of the tympanic membrane.The eustachian tube connects the middle ear with the nasopharynx, equalizing air pressure on either side of the tympanic membrane. The middle ear conducts sound vibrations to the inner ear. Inner ear The inner ear consists of closed, fluid-filled spaces within the temporal bone. It contains the bony labyrinth, which includes three connected structures the vestibule, the semicircular canals, and the cochlea. The inner ear receives vibrations from the middle ear that stimulate nerve impulses. These impulses travel to the brain, and the cerebral cortex interprets the sound. Auditory ossicles stapes (stirrup) Incus (anvil) Malleus (hammer) Semicircular canals Vestibule Cochlea Cochlear nerve Eustachian tube Tympanic membrane (eardrum) Helix Anthelix Lobule of auricle External acoustic meatus Assessment 31 Assessment Eyes Snellen charts The Snellen alphabet chart and the Snellen E chart are used to te st distance vision and measure visual acuity. Snellen alphabet chart Snellen E chart Age differences 20 20 In adults and children age 6 and older, normal vision is measured as 20/20. 20 50 For children age 3 and younger, normal vision is 20/50. 20 40 For children age 4, normal vision is 20/40. 20 30 For children age 5, normal vision is 20/30.To measure distance vision Have the patient sit or stand 20 (6. 1 m) from the chart. Cover his left eye with an light-tight object. Ask him to read the letters on one line of the chart and then to move downward to increasingly smaller lines until he can no longer discern all of the letters. Have him repeat the test top his right eye. Have him read the smallest line he can read with both eyes uncovered to test his binocular vision. If the patient wears disciplinal lenses, have him repeat the test vesture them. Record the vision with and without correction. withdrawnness vision Recording results Visual acuity is recorded as a fraction.The top number (20) is the distance between the patient and the chart. The bottom number is the lowest line on which the patient correctly identified the legal age of the letters. The larger the bottom number, the poorer the patients vision. The Snellen E chart is used for young children and adults who cant read. 32 Eyes and ears Test off-base vision using confrontation. Confrontation can help identify such abnormalities as homonymous hemianopsia and bitemporal hemianopsia. Heres how to test confrontation position or stand directly across from the patient and have him focus his gaze on your eyes. Place your hands on either ide of the patients head at the level of his ears so that theyre about 2 apart. Tell the patient to focus his gaze on you as you gradually bring your wiggling fingers into his visual field. Instruct the patient to tell you as soon as he can see your wiggling fingers he should see them at the same time you do. Repeat the procedure while retentiveness your hands a t the superior and inferior positions. Rosenbaum card The Rosenbaum card is used to evaluate near-vision. This small, handheld card has a series of numbers, Es, Xs, and Os in graduated sizes. Visual acuity is indicated on the right side of the hart in either distance equivalents or Jaeger equivalents. To measure near-vision Cover one of the patients eyes with an opaque object. Hold the Rosenbaum card 14 (35. 6 cm) from the eyes. Have the patient read the line with the smallest letters he can distinguish. Repeat the test with the other eye. If the patient wears corrective lenses, have him repeat the test while wearing them. Record the visual accommodation with and without corrective lenses. Near-vision Confrontation Does your patient wear glasses or contacts? Remember to test his vision with and without his corrective lenses. Assessment 33 Each upper eyelid hould cover the top pull in of the iris so the eyes look alike. Look for redness, edema, inflammation, or lesions on the lids. Eyelids The corneas should be clear and without lesions and should appear convex. Examining the corneas Examine the corneas by shining a penlight first from both sides and then from straight ahead. Test corneal aesthesia by lightly touching the cornea with a wisp of cotton. The irises should appear flat and should be the same size, color, and shape. Irises Corneas Inspecting the eyes With the scalp line as the starting point, determine whether the eyes are in a normal position. They should be bout one-third of the way down the face and about one eyes width apart from each other. Then assess the eyelids, corneas, conjunctivae, sclerae, irises, and savants. 34 Eyes and ears Each pupil should be equal in size, round, and about one-fourth the size of the iris in normal room light. exam the pupils Slightly darken the room. Then test the pupils for direct response (reaction of the pupil youre testing) and consensual response (reaction of the opposite pupil) by holding a penlight about 20 (51 cm) from the patients eyes, directing the light at the eye from the side. Next, test accommodation by placing your finger