Inspection and palpation for........
- General color and condition,
- cleanliness,
- dryness or oiliness, parasites,
- and lesions
- Amount and distribution of scalp, body, axillae, and pubic hair
Vision
- Visual fields
- Visual pathways
- Visual reflexes
- Pupillary light reflex
- Accommodation
Eyes
1. stand 20 feet away from chart
2. cover one eye with opaque card
3.read lowest line that they can distinguish
4. repeat on other eye
5. Perform with eyes uncovered for binocular vision
Snellen chart- 20 feet away/line they read
Normal acuity is 20/20
with or without corrective lenses
Subjective Data:
History of present health concern
Past health history
Family history
Lifestyle and health
practices
Assessments
Preparing the client
Equipment
Snellen or E chart
Hand-held Snellen card
or near-vision screener
Penlight
Opaque cards
Ophthalmoscope
- Position and alignment of the eyeball in the eye socket
- Bulbar conjunctiva and sclera
- Test pupillary reaction to light.
- Test accommodation of pupils.
Handheld vision chart
Normal acuity is 14/14 with or without corrective lenses
1. Cover 1 eye with opaque card
2. Hold Rosenbaum card 14 inches away
3.read line with 3 smallest letters
they can distinguish
4. repeat on opposite eye
5. Perform with corrective lenses
and without
Will assess CN VIII- Acoustic
visual fields for gross peripheral vision
Lets get ready....
How would you prep the client?
What equipment would you need?
Nursing History: Present Illness
- Body odor problems
- Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation)
- Changes in lesion appearance
- Feeling changes (pain, pressure, itch, tingling)
- Hair loss or changes
- Nail changes
- Family history
- Personal health history
- Family history
- Lifestyle and health practices
- Exposure to sun or chemicals
- Daily care of skin, hair, nails
- Usual diet and exercise patterns
Health Assessment of Skin, Hair, Nails, Eyes, Ears, Nose, Throat
Skin Cancer
Most common of cancer
- Three types: melanoma, basal cell carcinoma, squamous cell carcinoma
- Asians are less susceptible
Risk Factors
Not just for the doctor
- Sun exposure
- Nonsolar sources of ultraviolet radiation
- Medical therapies
- Family history and genetic susceptibility
- Moles
- Pigmentation irregularities
- Fair skin that burns and freckles easily; light hair
- Age
- Inspect lesions
- Examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions:
- Male gender
- Chemical exposure
- Human papillomavirus
- Xeroderma pigmentosum
- Long-term skin inflammation or injury
- Alcohol intake; smoking
- Inadequate niacin in diet
Alterations in Skin Integrity
What is your Skin?
The skin is a physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration.
Nails
Inspection:
Nail grooming and cleanliness, nail color and markings, shape of nails
Palpation: Assess texture and consistency, capillary refill
Scalp and Hair
Braden Scale
Inspect first.....
Skin Problems
Pressure Ulcers
Skin Lesions
We are looking for
- Note any distinctive odor
- Generalized color variations
- Skin breakdown
- Primary, secondary, or vascular lesions
Then Palpate ........
We Are Feeling for
- Lesions
- Texture
- Temperature and moisture
- Thickness of skin
- Mobility and turgor
- Edema
What you need....
A Wood’s lamp is a small handheld device that uses black light to illuminate areas of your skin. The light is held over an area of skin in a darkened room. The presence of certain bacteria or fungi, or changes in the pigmentation of your skin will cause the affected area of your skin to change color under the light.
- Gloves
- Examination light and penlight
- Magnifying glass
- Centimeter ruler
- Wood’s light
- Examination gown or drape
- Assessment Tool 14-1, Braden Scale For Predicting Pressure Sore Risk