Nursing
Faculty
LESSON ¹ 2 (PRACTICAL – 6 HOURS)
Theme 1: Health Assessment of
Skin, Hair and Nails.
Theme 2: Health Assessment of Head, Neck and Related Lymphatics.
Theme 3: Health Assessment of
Nose, Mouth, and Throat.
Aim: -To be able to perform health assessment of skin, hair and nails of the
patient and find out the disorders.
-To be able to perform physical assessment of nose, mouth and throat and
to show abnormal findings.
-To ddemonstrate
health assessment of head, neck and related lymphatics on clients of various ages, genders, and cultures.
Professional orientation of students: Think
of the skin as the body’s largest organ system- it covers 20 square feet of surface area in the average adult. The skin is the sentry that guards
the body from environmental stresses (e.g. trauma, pathogens, dirt) and adapts
it to other environmental influences (e.g. heat, cold)
The head and neck regions contain multiple sutures that make examination
of these areas complex. The scull encloses the brain; facial structures include
the eyes, ears, nose, and mouth. Structures of the neck include the upper
portion of the spine, the esophagus, the trachea, the thyroid gland, arteries,
veins and lymph nodes.
Methodology of Practical Class.
(9.00-12.00)
Algorithm of students’ communication
with patients with pathology in subject (communication skills) (for clinical
department):
During examination of
the patient students have to use such communicative algorithm:
Complaints and
anamnesis taking in patients
1. Friendly facial
expression and smile.
2. Gentle tone of
speech.
3. Greeting and
introducing.
4. Take complaints and
anamnesis in a patient.
5. Explain to the
patient results of his/her lab tests correctly and accessibly.
6. Explain to the
patient your actions concerning him/her (the necessity of hospitalization,
certain examinations and manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of
examination of patients with internal diseases
1. Friendly facial
expression and smile.
2. Gentle tone of
speech.
3. Greeting and
introducing.
4. Explain to a
patient, what examinations will be carried out and get his/her informed
consent.
5. Find a contact with
the patient and make an attempt to gain his/her trust.
6. Inform about the
possibility of appearing of unpleasant feelings during the examination.
7. Prepare for the
examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
8. Examination
(demonstration of clinical skill).
9. Explain to the
patient results of his/her lab tests correctly and accessibly.
10. Conversation
accomplishment.
Estimation of laboratory
and instrumental investigations
Informing about the
results of examination of patients with internal diseases
1. Friendly facial
expression and smile.
2. Gentle tone of
speech.
3. Greeting and
introducing.
4. Explain to a patient
results of his/her lab tests correctly and clearly.
5. Involve the patient
into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly
understood).
Planning and prognosis
the results of the conservative treatment
Friendly
facial expression and smile.
1. Gentle tone of
speech.
2. Greeting and
introducing.
3. Correct and clear
explanation of necessary treatment directions.
4. Discuss with a
patient the peculiarities of taking medicines, duration of their usage, possible
side effects; find out whether your explanations are clear for him/her or not.
5. Conversation
accomplishment.
Task 1. Work in groups. To
perform the assessment of skin, hair and nails of the patient.
Skin Assessment
|
|
Color
Vascular Lesions
Moisture Temperature Texture Mobility/Turgor Skin Lesions
|
Inspection of Nails
Color
Consistency
Smoothness
Length/Shape
Cleanliness
Normal Nail
Flat and slightly curved
Smooth
Uniform thickness
Pigment bands in a
dark-skinned person
Firm nail base
that adheres to nail bed
Color-depends on skin color
Inspection of Nails-Thickness
Thickening of nails (Hypertrophy)
Thinning of nails (Brittleness)
Inspection of Nails-Smoothness
Pitting of Nail
Beau’s Lines--transverse depressions
Inspection of Nails
Nail Clubbing
Capillary Refill
Nail Color
Exogenous Color Changes
Silver Nitrate
Gentian Violet
Endogenous Color Changes
Leukonychia (white spots or
streaks)
Yellow Nails
Green Nails
Color Changes cont.
Blue Nails
Bright Pink Nails
Vertical Brown Lines
Miscellaneous Nail Changes
Koilonychia
Onycholysis
Misc. Nail Changes cont.
Paronychia
Splinter Hemorrhages
Task.2
|
# |
Practicum Outline |
|
1. |
Nose, Mouth, and Throat 1. Internal and external
anatomy 2. Subjective data 3. Objective data 4. Abnormal findings |
|
2. |
1.Learn methods
of inspection and palpation of nose, mouth, and throat 2.Learn to record all
findings accurately |
EXAMINATION OF
Nose, Sinuses,
Mouth, and Oropharynx
|
|
I. Anatomy & Physiology II. Health History A. History of Trauma III C. Nose 1. Inspect a. Symmetry and contour 2. Palpate a. Tenderness b. Nasal patency D. Sinuses 1. Inspect frontal and
maxillary sinuses for inflammation and edema E. Mouth and Oropharynx 1. Inspect a. Unusual breath odors - pink, rough, midline
depression f. Hard and soft pallets
2. Palpate a. Palpate upper and lower lips
and tongue to evaluate muscle tone and surface structure 3. Examine oropharynx with tongue depressor and
penlight (glossopharyngeal vagus nerves) |
Demonstrate health assessment of the:
TASK 3. EXAMINATION
OF THE HEAD AND NECK
|
|
I. Anatomy & Physiology II. Health History A. History of Head Trauma III. Examination of the Head and Face A. Head 1. Inspect a. Erect and midline 2. Palpate a. Palpate scalp and hair
texture B. Face 1. Inspection a. Spontaneous facial expression
b. Color (pallor & cyanosis) 2. Palpation a. Palpate face for skin
tone, muscle tone, and contours 3. Auscultate a. Temporal arteries Cg. Tonsils
2. Palpate a. Palpate upper and lower
lips and tongue to evaluate muscle tone and surface structure 3. Examine oropharynx with tongue depressor and
penlight (glossopharyngeal vagus nerves) F. Neck 1. Inspect a. Symmetry 2. Lymph Nodes a. Inspect and palpate,
noting size, shape, delimitation, mobility, consistency, and tenderness 3. Trachea- inspect and palpate |
Seminar discussion
of theoretical issues. (12.00-14.00)
Student’s
Individual Work (14:15-15:00)
Students who have passed Moodle tests
the day before class are free from test control during the class
1. The client tells the nurse that his skin is
darker now than a week ago. Which condition could be responsible for this
change?
|
a. |
Exposure
to heat |
|
b. |
Exposure
to cold |
|
c. |
Exposure
to excess moisture |
|
d. |
Exposure
to ultraviolet light |
____ 2. What is the most important data for the nurse
to obtain from a client who has a persistent rash on both hands?
|
a. |
Age |
|
b. |
Gender |
|
c. |
Occupation
and hobbies |
|
d. |
Socioeconomic
status |
____ 3. The client, who caught the thumb in a drawer,
has a collection of blood at the base of the nail and asks you when this discoloration
will be gone. What is your best answer?
|
a. |
“Discoloration
that occurs under the nail is permanent.” |
|
b. |
“Exposing
the area to sunlight will cause the discoloration to fade.” |
|
c. |
“The blood
will be reabsorbed in about 2 weeks, just like any other bruise.” |
|
d. |
“The
blood will be gone when the nail completely grows beyond the injury in 3 to 4
months.” |
____ 4. You observe yellow-tinged sclera on a client with
dark skin. Based on this observation, what is your best action?
|
a. |
Examine
the soles of the client's feet. |
|
b. |
Nothing;
this is a normal finding on all people with dark skin. |
|
c. |
Inspect
the client's oral mucosa and hard palate for other indications of jaundice. |
|
d. |
Notify
the physician of the possibility that the client has hepatitis or another
liver disorder. |
____ 5. You observe clubbing of the fingers in an
older man. What is your interpretation of the significance of this finding?
|
a. |
You
should ask the client if this condition has been present since birth. |
|
b. |
This
finding is most commonly associated with chronic disorders of impaired gas
exchange. |
|
c. |
You
should ask the client about his occupation and hobbies and any other
activities involving exposure of the hands to harsh chemicals. |
|
d. |
Clubbing
of the fingers is a common age-related change and is considered a normal
finding among older adults, especially men. |
____ 6. What problem are you alerted to in a client
who has chronically inflamed soft tissue folds around the nail plates on all
fingers?
|
a. |
Probable
fungal infection |
|
b. |
Long-term
use of nail polish |
|
c. |
Poorly
controlled diabetes mellitus |
|
d. |
Frequent
intermittent exposure to water |
____ 7. The older client asks you if the white rings
around her eyes are cancer of the eye or cataracts. What is your best response?
|
a. |
“Yes,
they are actually benign tumors and do not need to be removed.” |
|
b. |
“No,
these rings are a normal change as people age and do not affect vision.” |
|
c. |
“No,
these rings may be early indications of glaucoma and should be evaluated by
your doctor.” |
|
d. |
“Yes,
these rings are immature cataracts and will need to be removed when they grow
large enough to affect your vision.” |
____ 8. What is the priority nursing diagnosis for the
older adult client who has very thin skin on the backs of the hands and arms?
|
a. |
Risk
for Injury |
|
b. |
Risk
for Infection |
|
c. |
Risk
for Disuse Syndrome |
|
d. |
Risk
for Imbalanced Body Temperature: hyperthermia |
____ 9. The client has two skin lesions, each the size
of a nickel, on his chest. Both lesions are flat and a darker color than the
rest of the client's skin. How would you document this finding?
|
a. |
Two
2-cm hyperpigmented patches |
|
b. |
Two 1-inch
erythematous plaques |
|
c. |
Two
2-mm pigmented papules |
|
d. |
Two
1-inch moles |
____ 10. What technique should you use to obtain a
specimen for culture from a client who has crusted skin lesions on the upper back
that indicate a possible bacterial infection?
|
a. |
Remove
several crusts and swab the underlying exudate. |
|
b. |
Remove
a crust from the center of the cluster of lesions and send it to the
laboratory. |
|
c. |
First,
dampen the culture swab with sterile water, and then roll the swab over the
central crusts. |
|
d. |
Apply
a gauze bandage to the area, remove it after 1 hour, and send the entire
gauze to the laboratory. |
Initial level of knowledge and skills are
checked by solving situational tasks for each topic, answers in test
evaluations and constructive questions.
(the
instructor has tests & situational tasks)
Student should know:
1. Identify
health history questions for assessment of skin, hair, and nails.
2. Differentiate
between normal and abnormal integumentary assessment
findings.
3. Identify
health promotion needs of clients based on findings of integumentary assessment.
4.
Understand the rationale and methods for inspection and palpation of skin
5. Identify
health history questions for assessment of the mouth, nose and throat.
6. Demonstrate
health assessment of mouth, nose and throat.
7. Differentiate
between normal and abnormal assessment findings of the mouth, nose and throat.
8.
Identify health promotion needs of clients based on findings of the mouth, nose
and throat assessment.
9. Learn the location and function of structures in the
head and neck
10. Learn to perform inspection and palpation of the head
and neck
11. Learn to
record all findings accurately
Student should be able to:
1. Communication skills with the patient
2. Demonstrate health assessment of the skin, hair, nails
3. Demonstrate health assessment of the mouth, nose and throat
4. Identify health history questions for assessment of
the head, neck, lymph nodes.
5. Demonstrate health assessment of the head, neck, lymph
nodes.
6. Differentiate between normal and abnormal assessment
findings of the head, neck, lymph nodes.
7. Identify health promotion needs of clients based on
findings of the head, neck, lymph nodes.
Correct answers of
test evaluations and situational tasks:
1. ANS: D
UV
light stimulates the production of melanin, which protects against the harmful
effects of sun exposure.
2. ANS: C
The location
of the rash suggests contact dermatitis. This condition is most often caused by
contact with irritating substances such as might be found in industrial
settings or associated with specific hobbies.
3. ANS: D
Unlike
hair growth, which is cyclic, nail growth is a continuous but slow process.
Total replacement of a fingernail from the matrix to the end of the finger
requires 3 to 4 months.
4. ANS: C
The
nurse can best observe jaundice in clients with dark skin by inspecting the
oral mucosa, especially the hard palate, for yellow discoloration. Sclera may
have subconjunctival fat deposits that show a yellow
hue. Foot calluses may appear yellow.
5. ANS: B
Clubbing
of the fingers is never a normal finding and is diagnostic for chronic
disorders that impair gas exchange.
6. ANS: D
The
condition, chronic paronychia, is common in people with frequent intermittent
exposure to water, such as homemakers, bartenders, and laundry workers.
7. ANS: B
The
rings, or arcus senilis of aging,
are fat deposits in the eye that occur with normal aging. Their presence is not
indicative of any disorder and does not interfere with vision in any way.
8. ANS: A
The
thinning skin, with a decreased attachment between the dermis and the epidermis,
is at an increased risk for injury in response to even minimal trauma or
shearing events.
9. ANS: A
Patches
are larger, flat areas of the skin. The information provided does not indicate
a mole or the presence of erythema.
10. ANS: A
The
infecting agent is present in the material underneath the crusts.
References:
Jarvis, C. (2011). Physical examination and health assessment. (6th ed.). Philadelphia: W.B. Saunders
 – Additional:
Weber, J. & Kelley, J.,
(2010). Health
assessment in nursing. (4th Ed.). Lippincott
ISBN: 978-0-781-78160-2
Weber, J. & Kelley, J.,
(2010). Health
assessment in nursing lab manual. (4th Ed.).
Lippincott ISBN: 978-0-781-78161-9
Mosby’s Dictionary of Medicine, Nursing, and
Health Professions,
(2009). (8th ed.)
St. Louis: Elsevier ISBN: 9780323052900
Venes, D. editor (2009) Taber’s
Cyclopedia Medical Dictionary (21th ed.).
Philadelphia: F.A. Davis. ISBN:
9780803615595
Methodical
instruction has been worked out by:
O. Krekhovska-Lepyavko,
MD, BSN, MSN
Methodical
instruction was discussed and
adapted at the Department sitting
June 12, 2013. Minute ¹ 13