Study guide for test 3 nur 101
Card Set Information
Study guide for test 3 nur 101
nursing 101 study guide test
skin, hair, nails, eyes, ears Assessment Lab
Tips for organizing the physical assessment and creating proper environment
Privacy, Quiet, Temperature of Room, Light
Hand Hygiene, short nails warm hands
when doing physical assessment on pt what are some general rules
work head to toe
compare one side to the other
use specific terminology
What are normal skin findings for older adults?
Loss of elasticity, and subcutaneous fat
Sweat Glands are less active
skin is thinner so it tears easily
what would expect to see when examining the hair of older adults?
they can have Hair loss
and sometimes their hair is coarse
the result of inadequate circulation
will heal without a scar
Burn (chemical Burn)
when describing a skin lesion you describe ....
Type or Structure
Size, shape, texture
what are the type or structures of skin lesions?
primary -appear initially to reaction in the internal or external environment
secondary - do not appear initially but result from primary lesion.
how do you describe size, shape and texture of lesion
circumcised, irregular, round, oval
flat, elevated, or depressed
fluid filled, has flakes,
solid, soft, hard, rough or thickened
skin lesion describe color
there may be no color, one color or many colors
as with ecchymosis starts dark red or blue then fades to yellow
when the color fades of a lesion are limited to the edges they are described as .....
what are the characteristics of a circumcised lesion?
the color change that occurs they are limited to the edges of the lesion
when the color change process of a lesion spreads all over the lesion it is called...
describe diffuse lesion
when the color changing process spreads over a large area of the lesion.
when describing a lesion what is meant by distribution?
location of the lesion on the body and symmetry or asymmetry of the findings in comparable body areas.
describing lesions what is configuration
refers to the arrangement of the lesions in relationship with each other
lesions arranged in a circle
describe infant nails
why do children bite their nails
fungus is common
what is capillary refill
the amount of time it take for color to come back in nail after pressing on it
should go back in 3 seconds
what is normal for infants skin
vernix caseosa -white greasy on baby when born
lanugo in premature-really fine hair
sacral hyperpigmentation in dark skinned babies
what is normal to see in the skin of children
when assessing the nail what do you look at
describe healthy oropharynx.
hard and soft palate pink and intact
no lesions or exudates
symmetrical rise of uvula
positive swallow reflex
how to assess for the gag reflex
touch the back of the soft palate with the tongue blade.
why is the absence of gag reflex a risk for the client?
it put the client at risk for aspiration
why would a nurse assess a client for gag reflex?
if pt is unresponsive and they need to provide oral care
what creates fontanelles in an infant?
how to assess for a malignant lesion
-elevation or enlargement