1. Health Assessment of skin and mental status
Day two:
Vital signs
HEALTH HISTORY
Physical assessment
Health Assessment of skin and mental status
Jerry Thompson RN, MSN

2. Vital Signs and Physical Assessment
At the completion of this class the student will be able to:
Describe factors that effect vital signs and how to measurement of them
Explain how to take a health history
Explain what is included in a physical assessment
Demonstrate performing a general survey / mental status exam
Discuss how to assess the skin

3. The Nursing Process What is the first step? What do you do?
What is the second step? What do you do?
What is the third step? What do you do?
What is the forth step? What do you do?
What is the fifth step? What do you do?
ADPIE

4. Professional Nursing Task Based Nurse Role Based Nurse
What do they do?
Tasks.. Such as
Vital signs
Dressing changes
Ambulating
Giving medications
What do they do?
Manage patient care
Includes tasks and also…
Collaboration with other health care professionals
Monitoring & follow through
MAKE DECISIONS

5. Vital Signs Chapter
Temperature, pulse, respiratory rate, blood pressure
Pain
Oxygen saturation also frequently measured
Vital signs are used to:
To establish baseline data to compare to for future measurements
Identify problems
Evaluate response to intervention
The most frequent measurements obtained by health care providers are those of temperature, pulse, blood pressure (BP), respiratory rate, and oxygen saturation.
Pain, a subjective symptom, is often called the fifth vital sign and is frequently measured with the others.
Measurement of vital signs provides data from which to determine a patient’s usual state of health (baseline data).
Assessment of vital signs provides data by which to identify nursing diagnoses, implement planned interventions, and evaluate outcomes of care.
Many factors such as the temperature of the environment, the patient’s physical exertion, and the effects of illness cause vital signs to change, sometimes outside an acceptable range.
An alteration in vital signs signals a change in physiological function and the need for medical or nursing intervention.
When you learn the physiological variables influencing vital signs and recognize the relationship of their changes to other physical assessment findings, you can make precise determinations about a patient’s health problems. Vital signs and other physiological measurements serve as the basis for clinical decision making and problem solving.

6. Temperature Alterations
Acceptable temperature range:
96.8° F to 100.4° F or 36° C to 38° C
Pyrexia / Hyperthermia (fever): important defense mechanism
Febrile/afebrile
Hypothermia
What causes Hyperthermia? Hypothermia?
Fever or pyrexia occurs because the body is unable to keep pace with a heat production mechanism. This can occur because the hypothalamus is unable to keep the “set point.” Pyrogens such as bacteria and viruses elevate body temperature.
Remember that fever is an important defense mechanism. Mild temperature elevations as high as 39° C (102.2° F) enhance the immune system of the body. But also recall that a fever increases oxygen demand and can stress the cardiac and respiratory systems.
Febrile means having fever; afebrile means not having fever.
The term fever of unknown origin (FUO) refers to a fever with an undetermined cause.
Hyperthermia is an elevated body temperature resulting from the body’s inability to promote heat loss or reduce heat production.
Malignant hyperthermia is a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.
Heatstroke [defined as a body temperature of 40° C (104° F) or more] occurs from prolonged exposure to the sun or high environmental temperatures. This may be seen in those who spend time outside, such as athletes and construction workers. Signs and symptoms include giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual disturbances, elevated body temperature, increased heart rate, and lower blood pressure.
•Heat exhaustion occurs when profuse diaphoresis results in water and electrolyte loss.
•Hypothermia occurs with exposure to cold. The core body temperature drops, and the body is unable to compensate.
[See Table 29-1 on text p. 446 Classification of Hypothermia.]
•Frostbite occurs when the body is exposed to subnormal temperatures. Ice crystals form inside the cell, and permanent circulatory and tissue damage occurs.

7. Assessing Body Temperature
Electronic Thermometer
Temporal Artery Thermometer
Chemical Dot Thermometer
Temperature sites:
Oral, rectal, axillary, and
tympanic membrane
This electronic thermometer has a blue probe for oral or axillary use and a red probe for rectal use.
Electronic thermometers provide two modes of operation: a 4-second predictive temperature and a 3-minute standard temperature. In day-to-day clinical situations, most nurses use the 4-second predictive mode.
Readings from electronic thermometers appear within seconds and are easy to read.
[Shown is Figure 29-4 from text p. 447
Shown is use of an electronic temporal artery thermometer in scanning a child’s forehead.
It measures the temperature of the superficial temporal artery. A handheld scanner with an infrared sensor tip detects the temperature of cutaneous blood flow by sweeping the sensor across the forehead and just behind the ear.
After scanning is complete, a reading appears on the display unit. Temporal artery temperature is a reliable noninvasive measure of core temperature.
[See also Box 29-6 on text p. 449 Procedural Guidelines: Measurement of Temporal Artery Temperature.]
[Shown is Figure 29-5 from text p. 447.]

8. Assessment of Pulse + Apical Rate = normal 60-100 Rhythm
Bradycardia < 60
Tachycardia > 100
Pulse deficit = Difference between radial and apical pulse rates
Rhythm
Dysrhythmia: irregular or regularly irregular
Strength: 4+, 3+, 2+ (normal), 1+, 0
Where would you assess the pulse of an infant?
Unresponsive and not breathing?
Assessment of the radial pulse includes measuring rate, rhythm, strength, and equality. When auscultating an apical pulse, assess rate and rhythm only.
Before measuring a pulse, review the patient’s baseline rate for comparison. Some practitioners prefer to make baseline measurements of the pulse rate as the patient assumes sitting, standing, and lying positions. Postural changes affect the pulse rate through alterations in blood volume and sympathetic activity. The HR temporarily increases when a person changes from a lying to a sitting or standing position.
When assessing the pulse, consider the variety of factors that influence the pulse rate. A single factor or a combination of these factors often causes significant changes. If you detect an abnormal rate while palpating a peripheral pulse, the next step is to assess the apical rate. The apical rate requires auscultation of heart sounds, which provides a more accurate assessment of cardiac contraction.
Assess the apical rate by listening to heart sounds. Identify the first and second heart sounds (S1 and S2). At normal slow rates, S1 is low pitched and dull, sounding like a “lub.” S2 is higher pitched and shorter, creating the sound “dub.” Count each set of “lub-dub” as one heartbeat. Using the diaphragm or bell of the stethoscope, count the number of lub-dubs occurring in 1 minute.
Two common abnormalities in pulse rate are tachycardia and bradycardia. Tachycardia is an abnormally elevated HR—above 100 beats/min in adults. Bradycardia is a slow rate—below 60 beats/min in adults.
Inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit, you and a colleague assess radial and apical rates simultaneously and then compare rates. The difference between apical and radial pulse rates is the pulse deficit. Pulse deficits are often associated with abnormal rhythms. [Practice with the class calculating pulse deficits.]
Normally, a regular interval occurs between pulses or heartbeats. An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm or dysrhythmia. A dysrhythmia threatens the ability of the heart to provide adequate cardiac output, particularly if it occurs repetitively. Identify a dysrhythmia by palpating an interruption in successive pulse waves or by auscultating an interruption between heart sounds. If a dysrhythmia is present, assess the regularity of its occurrence, and auscultate the apical rate. Dysrhythmias are described as regularly irregular or irregularly irregular.
To document a dysrhythmia, the health care provider often orders an electrocardiogram, Holter monitor, or telemetry monitor.
Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows with expiration.
This is a normal finding that you can verify by having the child hold his or her breath; the HR usually becomes regular.
The strength or amplitude of a pulse reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system leading to the pulse site. Normally, the pulse strength remains the same with each heartbeat. Document the pulse strength as bounding (4+); full or strong (3+); normal and expected (2+); diminished or barely palpable (1+); or absent (0). Include assessment of pulse strength in the assessment of the vascular system.
Assess radial pulses on both sides of the peripheral vascular system, comparing the characteristics of each. A pulse in one extremity is sometimes unequal in strength or absent in many disease states. Assess all symmetrical pulses simultaneously except for the carotid pulse. Never measure the carotid pulses simultaneously because excessive pressure occludes the blood supply to the brain.

9. Assessment of Respirations
Easy to assess
Respiratory rate: breaths/minute
Ventilatory depth: deep, normal, shallow
Ventilatory rhythm: regular/irregular
Diffusion and perfusion
What is the preferred method of assessing Respirations?
Accurate measurement requires observation and palpation of chest wall movement. [Table 29-5 on text p. 457 shows acceptable ranges of respiratory rate.]
Respirations are tied to all functions of body systems. A sudden change in respiration may indicate a problem or can be a normal physiological response.
Respiratory rate is age specific. Respiratory rate can be influenced by activity and age, as well as by illness, injury, or disease.
Ventilatory movements are described as deep, normal, or shallow. [Table 29-6 on text p. 457 presents alterations in breathing patterns.]
Remember that infants tend to breathe less regularly. Respiration is regular or irregular in rhythm.
You will evaluate respiratory processes of diffusion and perfusion by measuring the oxygen saturation of blood. The percentage of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin, or SaO2. This value should be between 95% and 100%.

10. Breathing Patterns Bradypnea Tachypnea Hyperpnea Apnea
12 to 20 for an adult.
bradypnea <12
tachypnea > 20
newborn / infant = 30 to 60 1 year old = 20 to 40 2 year old = 20 to 30 8 year old = 15 to year old = 15 to 20
Bradypnea
Tachypnea
Hyperpnea
Apnea
Hyperventilation
Hypoventilation
Cheyne-Stokes respiration
Kussmaul’s respiration
Biot’s respiration

11. Measurement of arterial oxygen saturation (SaO2)
Percent of hemoglobin that is bound with oxygen in the arteries
Usually 95% to 100%
Pulse oximeter
What can interfere with accurate assessment?
This is a portable pulse oximeter with digit probe.
Arterial oxygen saturation is measured through a pulse oximeter. SpO2 is a reliable estimate of SaO2 when it is higher than 70%. Values obtained with pulse oximetry are less accurate at saturations less than 70%.
Factors that affect light transmission or peripheral arterial pulsations affect the ability of the photodetector to measure SpO2 also Low hemoglobin level / poor circulation / CO
[See also Box on text p. 458 Factors Affecting Determination of Pulse Oxygen Saturation (SpO2).]
[Shown is Figure from text p. 458.]

12. Arterial Blood Pressure
Force exerted on the walls of an artery by pulsing blood under pressure from the heart
Systolic = Maximum peak pressure during ventricular contraction
Diastolic = Minimal pressure during ventricular relaxation
Pulse pressure = Difference between systolic and diastolic pressures
Blood pressure is the force exerted on the arterial wall by pulsing blood under pressure from the heart.
Blood flows throughout the circulatory system as a result of pressure changes. It moves from an area of high pressure to one of low pressure. Systemic or arterial BP, the BP in the system of arteries in the body, is a good indicator of cardiovascular health.
The contraction of the heart forces the blood under high pressure into the aorta. The peak of maximum pressure when ejection occurs is the systolic pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial walls at all times.
The standard unit for measuring BP is millimeters of mercury (mm Hg). This measurement indicates the height to which the BP raises a column of mercury. Record BP with the systolic reading before the diastolic reading (e.g., 120/80).
The difference between systolic and diastolic pressures is the pulse pressure. For a BP of 120/80, the pulse pressure is 40.

13. Physiology of Arterial Blood Pressure
Factors affecting arterial blood pressure:
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity
Blood pressure depends on cardiac output (CO). Cardiac output is the volume of blood ejected by the ventricles of the heart (stroke volume) multiplied by the heart rate.
Blood pressure depends on peripheral resistance. Peripheral resistance is determined by the tone of the vasculature and the diameter of the blood vessels. Blood flows through arteries, arterioles, capillaries, venules, and veins. The size changes to meet the needs of surrounding structures and tissues.
The volume of circulating blood affects blood pressure. Normal circulating volume is 5000 mL. Rapid infusion of volume elevates blood pressure. Decreased volume, which can be caused by hemorrhage or dehydration, causes blood pressure to fall.
The thickness or viscosity of blood affects the ease of blood flow through small vessels. Hematocrit, or percentage of red blood cells, determines viscosity.
Normal arterial walls are elastic and easily distensible. As blood pressure increases, the diameter of the vessels increases to accommodate the pressure. Distensibility prevents fluctuations in blood pressure. Systolic pressure is elevated more than diastolic pressure as a result of reduced arterial elasticity.
It is important to remember that each hemodynamic factor significantly affects the others.

14. Blood pressure levels (from http://www.heart.org)
Blood Pressure Category
Systolic mm Hg (upper #)
Diastolic mm Hg (lower #)
Normal
less than 120
and
less than 80
Prehypertension
120 – 139 or
80 – 89
High Blood Pressure (Hypertension) Stage 1
140 – 159
90 – 99
High Blood Pressure (Hypertension) Stage 2
160 or higher
100 or higher
Hypertensive Crisis (Emergency care needed)
Higher than 180
Higher than 110

15. Hypertension versus Hypotension
More common than hypotension
Thickening of walls
Loss of elasticity
Family history
Risk factors
Hypotension
Systolic <90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow to vital organs
Orthostatic/postural
•Hypertension is more common than hypotension. Diastolic readings greater than 90 mm Hg and systolic readings greater than 140 mm Hg define hypertension.
Hypertension is asymptomatic; hypotension causes pallor, skin mottling, clamminess, confusion, increased heart rate, and decreased urine output.
Modifiable risk factors include obesity, smoking, alcohol consumption, and high salt. A person has no control over family history. Higher incidence of high blood pressure is seen in those with diabetes, of African American descent.
[See also Table 29-8 Classification of Blood Pressure for Adults Ages 18 and Older, Table 29-9 Antihypertensive Medications, and Table Recommendations for Blood Pressure Follow-up, all on text p. 460.]
Orthostatic or postural hypotension occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position. Patients who are dehydrated, anemic, or on prolonged bed rest and those who have had recent blood loss are at risk for orthostatic hypotension.
Assess for orthostatic hypotension during measurements of vital signs by obtaining BP and pulse with the patient supine, sitting, and standing.

16. Pain
ALWAYS assess for pain when taking vitals and after providing pain relief measures
Location / character / Level / what can help to relieve?
Rate on a Scale of 1 to 10

17. Pain assessment PQRST P = Provocation and Palliation
What causes it? What makes it better? What makes it worse?
Q = Quality and Quantity
How does it feel, look or sound? How much of it is there?
R = Region and Radiation
Where is it? Does it spread?
S = Severity and Scale
Does it interfere with activities? How does it rate on a severity scale of 1 to 10?
T = Timing and Type of Onset
When did it begin? How often does it occur? Is it sudden or gradual

18. Health History Primary subjective data
Biographical data : name, age, sex
Chief complaint / reason for visit
History of present illness
History of other illnesses
Family history of illnesses
Review of systems head to toe (asking questions, receiving subjective data)
Life style = personal habits, diet, sleep patterns, amount of exercise etc…
Social data = support systems, occupation
Psychological data, observations of both verbal and nonverbal queues.

19. Description of Chief complaint
When did the symptoms first appear?
Was it sudden or gradual?
How often does the problem occur?
Exact location of distress?
Character of the complaint
Intensity of pain / quality of sputum / amount of discharge …
Factors that aggravate or relieve symptoms

20. Methods of Data Collection
Patient-centered interview = An organized conversation with the patient
Set the stage (preparation, environment, greeting).
Set an agenda/gather information about patient’s concerns.
Collect the assessment or nursing health history; assure the patient of confidentiality.
Terminate the interview (cue the end).
The best clinical interview focuses on the patient, not on your own agenda.
A successful interview requires preparation. Collect available information about the patient before starting the interview, prepare the interview environment, and time the interview to avoid interruptions.
A good interview environment is free of distractions, unnecessary noise, and interruptions. Remove any barriers to privacy.
[See Box 16-2 on text p. 211 Focus on Older Adults.]
During the interview, you will conduct a nursing health history. The history collects information regarding patients’ current level of wellness, as well as a review of body systems, family history, sociocultural history, spiritual health, and mental and emotional reactions. [More discussion of the health history is provided on an upcoming slide.]
Be sure to assure the patient that any information obtained remains confidential and is used only by health care professionals who provide his or her care. The Health Insurance Portability and Accountability Act (HIPAA) regulations require patients to sign an authorization before you collect personal health data.
As you conclude the interview, you summarize your discussion with the patient and check for accuracy of the information collected.
Give your patient a clue that the interview is coming to an end. This helps the patient maintain direct attention without being distracted by wondering when the interview will end and also gives the patient an opportunity to ask additional questions.

21. Interview Techniques Open-ended vs. closed-ended questions
Back-channeling
Probing
Because a patient’s report includes subjective information, validate data from the interview later with objective data.
Obtain information (as appropriate) about a patient’s physical, developmental, emotional, intellectual, social, and spiritual dimensions.
[Review each technique with the class. Ask the class for examples of each. Open-ended questions cannot be answered with “yes” or “no,” whereas closed-ended ones can be answered with one or two words. Back-channeling, such as “uh-huh” or “go on,” reinforces the patient.]
[Examples of closed-ended and open-ended questions are shown in Box 16-3 on text p. 213.]
How you conduct the interview is just as important as the questions you ask.
A skillful interviewer adapts interview strategies based on the patient’s responses.
During the interview, you are responsible for directing the flow of the discussion so your patient has the opportunity to freely contribute stories about his or her health problems to enable you to get as much detailed information as possible.
Always clarify or validate any information about which you are unclear.
During an assessment interview, encourage patients to tell their stories about their illnesses or health care problems.

22. Physical Examination Chapter 30 ,
Assessment of each body system
Follows the nursing history
Systematic and organized
Head-to-toe approach
•Some tips will help you with your examination:
Compare both sides for symmetry.
If the patient is seriously ill, first assess the body system that is most at risk.
If the patient fatigues easily, allow a rest period between assessments.
Perform painful procedures near the end of the assessment.
Use accepted medical terms and abbreviations to keep notes brief.
Record quick notes during the examination, and complete larger documentation notes at the end of the examination.

23. Techniques of Physical Assessment
Inspection
Palpation
Percussion
Auscultation
•The four techniques used in a physical examination are inspection, palpation, percussion, and auscultation.

24. Inspection Use adequate lighting.
Use direct lighting to inspect body cavities.
Inspect each area for size, shape, color, symmetry, position, and abnormality.
Position and expose body parts as needed so all surfaces can be viewed but privacy can be maintained.
When possible, check for symmetry.
Validate findings with the patient.
What do you assess by inspection?
•To inspect, carefully look, listen, and smell to distinguish normal from abnormal findings.
•Recognize normal and abnormal.
•Inspection is the simplest of the five assessment skills.
[Ask the class: Why is olfaction an important part of your assessment? Discuss: Olfaction helps to detect abnormalities that cannot be recognized by any other means. For example, when a patient’s breath has a sweet, fruity odor, assess for signs of diabetes.]
[Table 30-4 (on text p. 493) provides a list of characteristic odors and the conditions that they may indicate.]

25. Palpation Used to gather information
Use different parts of hands to detect different characteristics
Hands should be warm, fingernails short.
Start with light palpation; end with deep palpation.
What do you assess by Palpation?
•Always tell the patient what you are doing.
•Place the patient in a comfortable position, and encourage the patient to relax.
•Palpate sensitive areas last.
•Use different parts of the hand to detect different characteristics. The palmar surface of the hand and finger pads is more sensitive than the fingertips and should be used to determine position, texture, size, consistency, masses, fluid, and crepitus. Assess body temperature by using the dorsal surface or back of the hand. The palmar surface of the hand and fingers is more sensitive to vibration. Measure position, consistency, and turgor by lightly grasping the body part with the fingertips.
[Table 30-5 (on text p. 494) provides examples of characteristics measured by palpation.]
[Images are Figures 30-1 and 30-2 (on text p. 494) and illustrate the use of different parts of the hands, as well as palpation pressure.]

26. Percussion Tap body with fingertips to produce a vibration.
Sound determines location, size, and density of structures.
•You need to know the various densities of structures to locate organs or masses, to map their boundaries, and to determine their size.
•An abnormal size suggests a mass or air or fluid within an organ or cavity.
•Developing the skill of percussion requires practice.

27. Auscultation Involves listening to sounds
Learn normal sounds first before identifying abnormal sounds or variations.
Requires a good stethoscope
Requires concentration and practice
•Some sounds you can hear without assistance; other sounds require the use of a stethoscope.
•Chapter 29 describes the parts of the stethoscope and its general use.
•Becoming proficient in auscultation requires that you recognize the sounds produced by body parts and the best locations for hearing sounds.
•The bell of the stethoscope is used to hear low-pitched sounds and the diaphragm for high-pitched sounds.
[Box 30-2 (on text p. 495) provides ways to practice using techniques of caring for the stethoscope.]
[Ask the class: How can you tell the difference between body sounds and extraneous noise? Discuss: Practice! By practicing with the stethoscope, you become proficient at using it and realize when sounds are clear and when extraneous sounds are present. Extraneous sounds created by rubbing against the tubing or chest piece interfere with auscultation of body organ sounds. By deliberately producing these sounds, you learn to recognize and disregard them during the actual examination.]

28. Bed Side Assessment
Your lab “final” will consist of a Bed Side Assessment
Vital signs
General Survey & Mental Status
Skin
Chest / Lungs
Heart & Major Vessels
Peripheral Vascular Assessment
Abdominal Assessment
Neurological Assessment

29. General Survey / Mental Status
what are we assessing?
•You can learn a lot about your patients before you ever lay hands on them.
•By looking at your patient, you will be able to assess:
Gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, signs of patient abuse, and signs of substance abuse. Always remember how age, gender, culture, and ethnicity affect your patient.
Box 30-3 (on text p. 497) provides clinical indicators of abuse.
Box 30-4 (on text p. 498) provides behaviors that are suspicious for substance abuse.
Box 30-5 (on text p. 498) provides questions for assessing dietary history for older adults.
•We just discussed vital signs in Chapter 29. Remember to incorporate that knowledge.
•Height and weight reflect a person’s overall level of health. It will be important to obtain a diet history for your patient.
[Table 30-6 (on text p. 499) presents a guideline for weight based on height.]
[Table 30-7 (on text p. 499) provides nursing history for weight assessment.]
[Image is Figure 30-3 (on text p. 498), Measurement of infant length.]

30. General Survey / Mental Status documentation
Slender female with good posture and steady gait. Cooperative and friendly, able to maintain eye contact while conversing. Speech at normal rate and easily understood, she is oriented to person, place and time and situation. Able to express thoughts clearly.

31. Skin Integument Color Moisture Temperature Texture Turgor Pigmentation
Cyanosis
Jaundice
Erythema
Moisture
Temperature
Texture
Turgor
The integumentary system refers to the skin, hair, scalp, and nails.
Observe for cyanosis (bluish discoloration) of the lips, nail beds, palpebral conjunctivae, and palms. The best site to inspect for jaundice (yellow-orange discoloration) is the patient’s sclera. You can see normal reactive hyperemia, or redness, most often in regions exposed to pressure such as the sacrum, heels, and greater trochanter. Inspect for any patches or areas of skin color variation. Localized skin changes such as pallor or erythema (red discoloration) indicate circulatory changes. For example, an area of erythema is caused by localized vasodilation resulting from sunburn, inflammation, or fever.
Texture refers to the character of the surface of the skin and how the deeper layers feel. By palpating lightly with the fingertips, you determine whether the patient’s skin is smooth or rough, thin or thick, tight or supple, and indurated (hardened) or soft.
[Ask your students: Why do you need to assess your patient’s skin? Discuss: to assess oxygenation, circulation, nutrition, local tissue damage, and hydration.]
[Table 30-8 (on text p. 500) provides nursing history for skin assessment.]
[Table 30-9 (on text p. 501) presents skin color variations. You need to remember to consider ethnicity.]
[Table (on text p. 501) lists physical findings of the skin indicative of substance abuse.]
[Ask your students: What abnormalities should you look for? Discuss: cyanosis, pallor, jaundice, erythema, petechiae]
[Images are Figure 30-4 (on text p. 500), A cross-section of the skin reveals three layers: epidermis, dermis, and subcutaneous fatty tissues; and Figure 30-5 (on text p. 502), Assessment of skin turgor.]

32. Skin (cont’d) Vascularity Edema Lesions ABCD: Asymmetry
Border irregularity
Color
Diameter
The circulation of the skin affects color in localized areas and leads to the appearance of superficial blood vessels. Vascularity occurs in localized pressure areas when patients remain in one position. Vascularity appears reddened, pink, or pale. With aging, capillaries become fragile and are more easily injured. Petechiae are nonblanching, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers.
Direct trauma and impairment of venous return are two common causes of edema. Inspect edematous areas for location, color, and shape. The formation of edema separates the surface of the skin from pigmented and vascular layers, masking skin color. Edematous skin also appears stretched and shiny. Palpate edematous areas to determine mobility, consistency, and tenderness. When pressure from the examiner’s fingers leaves an indentation in the edematous area, this is called pitting edema.
To assess the degree of pitting edema (shown), press the edematous area firmly with the thumb for several seconds, and release. The depth of pitting, recorded in millimeters, determines the degree of edema. For example, 1+ edema equals a 2-mm depth, 2+ edema equals a 4-mm depth, 3+ equals 6 mm, and 4+ equals 8 mm.
Assess for skin lesions or skin cancer, and take the opportunity to educate the patient.
Use the ABCD mnemonic to assess the skin for any type of carcinoma:
Asymmetry—look for an uneven shape
Border irregularity—look for edges that are blurred, notched, or ragged
Color—look for pigmentation that is not uniform; variegated areas of blue, black, and brown and areas of pink, white, gray, blue, or red are abnormal
Diameter—look for areas greater than the size of a typical pencil eraser
[Box 30-6 (on text p. 503) shows types of primary skin lesions.]
[Box 30-7 (on text p. 504) shows skin malignancies.]
[Box 30-8 (on text p. 505) provides evidence-based practice for skin assessment.]
[Image is Figure 30-6 (on text p. 502), Assessing for pitting edema.]

33. Skin (cont’d)

34. Assessment Condition of the Skin documentation
Client has no current complaints associated with the skin. Skin color is uniform and warm to touch. Skin intact with no moisture, edema or lesions noted. Skin turgor is good with no tenting.

35. HESI Go to: https://evolve.elsevier.com COURSE ID: 10358_nhaugen_1007
 USE SAMUEL MERRITT WHEN SETTING UP AN ACCOUNT

36. What did we cover today? Vital signs Health history
Physical assessment
Assessing General survey & the skin