Introducing 

Prezi AI.

Your new presentation assistant.

Refine, enhance, and tailor your content, source relevant images, and edit visuals quicker than ever before.

Loading…
Transcript

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

Assessment

Distance Visual Acuity

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

Objective Data

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

Assessment of the ears

Near Visual Acuity

External Ear

  • 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

Otoscope exam

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

Other Abnormalities

Weber and Rinne test

Will assess CN VIII- Acoustic

visual fields for gross peripheral vision

Confrontation

corneal light reflex

cover test

positions test

accommodation

Cataracts

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
Learn more about creating dynamic, engaging presentations with Prezi