Refers to the paleness of skin in one area when compared to another part of the body.
In light-skinned clients: extreme paleness; skin appears white; loss of pink or yellow tones.
In dark-skinned clients: a loss of red tones.
May be related to poor circulation or a low hemoglobin level (anemia).
Best sites to assess for pallor include the oral mucous membranes, conjunctiva, nail beds, palms, and soles of feet.
A blue-gray coloration of the skin, often described as ashen.
If seen in the lips, tongue, mucous membranes, and facial features, it is known as central cyanosis and is associated with hypoxia.
In newborns, acrocyanosis, which is bluish discoloration of palms and soles in the first few hours to days of life, if normal.
Cold causes the lips to turn blue but the tongue is not affected. Cyanosis may also be seen in the extremities, especially hands and feet, after exposure to extreme cold.
Yellow discoloration caused by accumulation of bile pigments in the skin.
Often associated with liver disorders.
Best sites to assess for jaundice include the sclear, mucous membranes, hard palate of the mouth, palms, and soles.
Jaundice in the newborn is a normal finding in the first few weeks of life unless there is blood incompatibility or a congenital disorder.
A widespread, diffuse area of redness.
Generalized redness of the face and body may occur as a result of fever, excessive room temp, sunburn, polycythemia (an abnormal increase in red blood cells), vigorous exercise, or certain skin conditions, such as rosacea.
A reddened area.
Associated with rashes, skin infections, prolonged pressure on the skin, or application of heat or cold.
Bruised (blue-green-yellow) area.
May be seen anywhere on the body.
The color will vary based on the age of the injury.
May indicate physical abuse, internal bleeding, side effect to medication, or bleeding disorder.
Refer to Chapter 9 to review assessing for abuse.
Tiny, pinpoint red or reddish-purple spots.
Visible in the skin due to extravasation (leakage from vessels) of blood into the skin.
May be associated with a variety of disorders and medications.
Bluish marbling of the skin.
Occurs in light-skinned clints, especially when cold.
In newborns mottling indicates overstimulation of the autonomic nervous system.
Refers to the elasticity of the skin.
Provides data about hydration status.
To assess turgor:
Life ("pinch up") a fold of skin and allow it to return to its normal position
Normally, skin returns immediately to its original position.
Skin that tends to stay pinched for a few seconds (tenting) may be a sign of dehydration.
Elasticity decreases with ae, so tenting may also be seen with normal aging.
Edema or scleroderma creates tension, preventing the skin from being pinched up.
An excessive amount of fluid in the tissues.
Common in clients with CHF, kidney disease, peripheral vascular disease, or low albumin levels.
Trace: A minimal depression is noted with pressure.
+1: Creates a depression of about 2mm. No visible distortion and rapid return of skin to position.
+2: Creates a depression up to 4mm in depth that disappears in about 10-15 seconds.
+3: Creates a depression of approximately 6mm in depth that lasts about 1-2 minutes. The area appears swollen.
+4: Creates a depression up to 8mm in depth that persists for about 2-3 minutes. The area is grossly edematous.
Variation in pigment.
Break in continuous tissue.
Normal variations include:
Millia: White raised areas on the nose, chin, and forehead of newborns.
Nevi: Moles, freckles, birthmarks.
Skin Tags: Tiny tags or buds of skin usually around skin creases in middle and older adults.
Striae: Silver-to-pink stretch marks in pregnant women, women who have had children, and anyone who has experienced significant weight fluctuations.
Primary Skin Lesions: develop as a result of disease or irritation. The pustules of acne are an example.
Secondary Skin Lesions: Develop from primary lesions as a result of continued illness, exposure, injury, or infection, such as the crusts that form from ruptured pustules.
When you observe a lesion-
Evaluate it for size, shape, pattern color, distribution, texutre, surface relationship, exudate, tenderness, pain, or itching.
Evaluate all skin lesions for the possibility of malignancy, especially those located in a site exposed to chronic rubbing or other trauma.
Warning signs of malignant lesions with ABCDE
D-Diameter Greater than 0.5 cm
E-Elevation Above the Skin Surface
See: The table at the end of Procedure 19-2, Abnormal Atlas at the end of Chapter 19 (V2)
Lack of pigment.
Occurs along the temples and in the conter of the scalp
Alopecia Areata: a benign autoimmune disorder.
Excess facial or trunk hair
may be due to endocrine disorders or steroid use
Head Lice Infestation
A fungal infection of the nail
A large head in an adolescent or adult
A disorder associated with excess growth hormone
An abnormally small head size
Seen in clients with certain types of mental retardation
An accumulation of excessive cerebrospinal fluid
A head that is growing disproportionally faster than the body in infants and children can be an indicator
An everted eyelid
Commonly seen in older adults secondary to loss of skin tone
An inverted eyelid
Can lead to corneal damage
Drooping of the eyelid
May be seen in clients who have experienced a stroke or Bell's Palsy
See: Chapter 19, Procedure 19-5, and Abnormal Atlas (V2)
The white of the eye
Jaundice or yellowing of the skin and/or the sclera (white) of the eye
May be seen with glaucoma (an increase in intraocular pressure)
Miosis of Pupils
Often results from medications to treat glaucoma
May be seen with central nervous system disorders such as stroke, head trauma, or cranial nerve injuries.
In some individuals, anisocoria may be normal
Reactive to Light
Used to assess equilibrium
Have client stand with feet together and eyes closed.
The client should be able to maintain balance with minimal swaying.
Swaying and moving (positive Romberg) may indicate a vestibular or cerebellar disorder.
Inflamation of the oral mucosa
Thick, elevated white patches in the mouth that do not scape off
May be precancerous lesions
White, curdy patches that scrape off and bleed indicate thrush (a fungal infection)
Inflamation of the tongue
Excessive curvature of the thoracic spine
Accentuated lumbar curve
Lateral "S" deviation of the spine
Developed in an unusual position
Contracting, or emptying, of the ventricles
Relaxation, or filling, phase of the ventricles
The area of the chest over the heart
Point of Maximal Impulse
A small pulsation at the 5th ICS midclavicular line
2nd ICS Right Sternal Border
2nd ICS Left Sternal Border
4th ICS Left Sternal Border
5th ICS MCL
A whooshing sound caused by turbulent blood flow through the carotid artery
Narrowing from plaque
Olfactory-Sense of smell
Occulomotor-Controls pupillary reaction to light
Trigeminal-Recieves sensations from the face
Abducens-Abducts the eye
Spinal Accessory-Shrug and head movement
Hypoglossal-Swallowing, Speach, Tongue Movement
Involuntary contraction, when testing reflexes, that continue after the first contraction is elicited by the hammer
Tapping your fingers on the skin using short strokes to produce sounds that allow you to dtermine location, size, and density of underlying structures.
The use of hearing to gather data.
The use of touch to gather data
The loss of body mass that can not be reversed nutritionally