Lecture 3 K. Hendrickson PhD, RN Fall 2013

Lecture 3 K. Hendrickson PhD, RN Fall 2013
NSG 310 Health Assessment Lecture 3 K. Hendrickson PhD, RN Fall 2013

Mental Health and Abusive Behavior Assessment
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Chapter 7 Mental Health and Abusive Behavior Assessment

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
What is Mental Health? Mental health: State of well-being – ability to realize one’s own abilities. Can cope with normal stresses of life. Can work productively Able to contribute to community. Changes in people’s lives may affect mental health: Periodic assessment of mental health and mental status is required.

What is Mental Status? Mental status: Intellect Emotion Psychology
Degree of competence/functioning that a person shows in the areas of: Intellect Emotion Psychology Personality

Experiences that may affect Mental Health
Abusive experiences such as: Alcohol abuse Drug abuse Personal abuse (aka interpersonal violence) Interpersonal violence: Is not an illness, but is a crime. Is a human rights violation. Can have negative impacts on mental health

Anatomy and Physiology
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology Limbic system called emotional brain because it regulates memory and basic emotions such as fear, anger, and sex drive. Structures of limbic system: Limbic lobe Cingulate gyrus Hippocampus Amygdala Thalamus Portions of the hypothalamus These structures enable communications between limbic system and cerebral cortex. The Limbic System is the area of the brain that regulates emotion and memory. It directly connects the lower and higher brain functions. It influences emotions, the visceral responses to those emotions, motivation, mood, and sensations of pain and pleasure Example: when a person sees something that jogs a happy memory – Communication occurs among the occipital lobe (vision), the prefrontal lobe for memory, and the limbic system for happy emotion associated with that memory.

“limbic lobe” to refer to the part of the cerebral cortex that forms a rim (limbus is Latin for rim) around the corpus callosum (The corpus callosum (Latin: tough body), is a wide, flat bundle of neural fibers the longitudinal fissure. It connects the left and right cerebral hemispheres and facilitates interhemispheric communication. It is the largest white matter structure in the brain, consisting of 200–250 million contralateral axonal projections.) LIMBIC System – THALAMUS: Thalamus means “inner room” in Greek, as it sits deep in the brain at the top of the brainstem. The thalamus is called the gateway to the cerebral cortex, as nearly all sensory inputs pass through it to the higher levels of the brain. (2) HYPOTHALAMUS: The hypothalamus sits under the thalamus at the top of the brainstem. Although the hypothalamus is small, it controls many critical bodily functions: Controls autonomic nervous system Center for emotional response and behavior Regulates body temperature Regulates food intake Regulates water balance and thirst Controls sleep-wake cycles Controls endocrine system. The pituitary gland extends from the hypothalamus. (3) CINGULATE GYRUS: The Cingulate (to surround) Gyrus (fold), is part of the cerebrum gray matter surrounding and directly connected to the parts of the inner Limbic System. The Cingulate Gyrus serves as a conduit of messages to and from the inner Limbic System. (4) AMYGDALA: The Amygdala is important for making associations across stimulus modalities (a certain fragrance often elicits an associated visual image). It appears to be responsible for the influence of emotional states on sensory inputs. This produces a spectrum of sensory perceptions from apparently identical stimuli (ex. the sound of one's own motorcycle is never perceived as noise). Thought to be responsible for face recognition. (5) HIPPOCAMPUS: The Hippocampus is very important in the transition of information from short to long term memory, Since the Hippocampus is also part of the Temporal Lobe, damage to that portion of the brain can result in a loss of memory.

Anatomy and Physiology: Neurotransmitters
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Neurotransmitters

Neurotransmitters & Mental Health
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Neurotransmitters & Mental Health Norepinephrine: excites or elevates Serotonin: stabilizes Dopamine: feel good Histamine: numbs Acetylcholine: tremors Gamma-aminobutyric acid (GABA): sedating

Step 1: Synthesis of neurotransmitter from precursor molecules (Q,R,S) Step 2: Storage of neurotransmitter in vesicles Step 3: Release of transmitter in response to an action potential (vesicles fuse with the terminal membrane and discharge contents) Step 4: Action at receptor: transmitter binds to receptor on post-synaptic cell, causing a reaction in that cell. Step 5: Termination: transmitter dissociates from its receptor and is removed from synaptic gap via (A) reuptake in to presynaptic nerve, (B) enzymatic degradation, or (C ) diffusion away from the gap.

General Health History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. General Health History Because data needed for mental health assessment are collected by talking with patient, nurse collects data about mental status during the health history: This is a deviation from assessments of specific body systems when data collection for history is performed prior to examination. During history, nurse determines patient’s appearance, behavior, and cognitive function compared with characteristics of a healthy personality.

General Health History
Data collection begins upon first seeing patient: Is patient dressed appropriately for weather? Does his or her mood seem appropriate? Is affect (emotional state) appropriate? What is patient’s body posture? Slumped over and looking at ground with a sad facial expression, or walking tall with a brisk step and a smiling face? What is tone of voice? Monotone or happy, expressive tone? Does conversation flow in logical sequence?

GHH: Present Health Status Questions
Are you having any medical problems? What medications are you taking? Side effects of some medications may cause changes in mood and behavior; also, nurse needs to know if patient is taking medications for mental disorders. Medical and Toxic Effects Central Nervous System Infectious Metabolic/Endocrine Cardiopulmonary Other Alcohol Cocaine Marijuana Phencyclidine (PCP) Lysergic acid diethylamide (LSD) Heroin Amphetamines Jimson weed Gamma-hydroxybutyrate (GHB) Benzodiazepines Prescription drugs Subdural hematoma Tumor Aneurysm Severe hypertension Meningitis Encephalitis Normal-pressure hydrocephalus Seizure disorder Multiple sclerosis Pneumonia Urinary tract infection Sepsis Malaria Legionnaire disease Syphilis Typhoid Diphtheria Human immunodeficiency virus (HIV) Rheumatic fever Herpes Thyroid disorder Adrenal disorder Renal disorder Hepatic disorder Wilson disease Hyperglycemia Hypoglycemia Vitamin deficiency Electrolyte imbalances Porphyria Myocardial infarction Congestive heart failure Hypoxia Hypercarbia Systemic lupus erythematosus Anemia Vasculitis *Adapted from Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am. May 2000;18(2): [2]

Past Mental Health History: Questions
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Past Mental Health History: Questions In the past, have you experienced any behaviors that could indicate a mental health problem? If yes, how have you coped in the past? Did these strategies work for you? Do you have any blood relatives who have behaviors that could indicate a mental health problem? If yes, describe the behavior they experience. Some people have witnessed violence at home: Did you have any experience with violence?

Personal & Psychosocial History: Self-Concept Questions
How have you been feeling about yourself? Do you consider your present feelings as being a problem in every day life? How would you describe yourself to others? What are your best characteristics? What do you like about yourself?

Personal and Psychosocial History: Interpersonal Relationship Questions How satisfied are you with your interpersonal relationships? Are there people you feel you can talk to about your feelings? Because abuse or violence have become more common, all patients should be asked these questions: Have you been physically injured by someone in your home over the last year? Are you fearful of anyone you have had a relationship with? Do you feel safe?

Stressors Stressors: Have there been any recent changes in your life?
Have these affected your stress level? What are major stressors in your life? How do you deal with stress? Are those methods effective for you?

Anger Anger: We all fight at home: Have you been feeling angry?
Do you feel angry now? How do you react when angry? Verbally, physically, or do you keep anger inside? Can you talk about what causes your anger? We all fight at home: What happens when you and your partner fight?

Alcohol and Drug Use Every adult and adolescent should be asked about alcohol and recreational drug use to determine if it is a health problem. Alcohol use: How often do you drink alcohol, including beer, wine, or liquor? Recreational drug use: Do you ever use recreational drugs? If yes, tell me about your drug use.

Problem-Based History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History Commonly reported problems of mental health include: Depression Anxiety Altered mental status Common problems of abusive behaviors include: Alcohol abuse Drug abuse Interpersonal violence

Problem-Based History: Depression Assessment
Note gender and age of patient: Women are at risk for depression 2:1 over men. It is most common between the ages of 25 and 44. Pay special attention to: Facial expression Eye contact Body language Tone of voice

Problem-Based History: Depression Questions
During past month, have you been feeling down, depressed, or hopeless? Have you had little interest or pleasure in activities? Are you able to fall asleep and stay asleep? Have you lost or gained weight recently? Describe your mood: Do you have crying spells? Is it hard to concentrate? Have you been more irritable? How often have you had those feelings? How long did they last? Beck Depression Inventory

Problem-Based History: Depression Questions
Do you have friends you can trust and who are available when you need them? Have you had feelings like this before? What did you do about depressive feelings then? Have you ever thought of escaping by hurting yourself or ending your life? If yes, do you feel like this now? Do you have a plan for hurting yourself? Have you told anyone else about your plan? What would happen if you were dead? What has kept you from hurting yourself in the past?

Problem-Based History: Anxiety Questions
Have you had difficulty concentrating or making decisions? Are you able to fall asleep and stay asleep? Have you been more irritable? Are your muscles tense? Do you feel a tightening in your throat? Have you felt nauseated? Does your heart race? Do you have to urinate more than usual? Have you noticed a change in your feelings? If yes, describe. What initiated those feelings?

Problem-Based History: Altered Mental Status
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Altered Mental Status Changes in mental status may become evident when there is change in patient’s orientation to time, place or person, attention span, or memory. When orientation becomes a concern while taking history, nurse asks questions to collect additional data. Long-term memory can be assessed during history by asking patient where he or she was born or about previous surgeries.

Problem-Based History: Altered Mental Status
Orientation: Name? What year is it? Where are you? Memory: Ask patient to repeat three unrelated objects. Calculation ability: You buy fruit that cost $2.50. You give the cashier $3.00. What should your change be? Communication skills: Repetition Reading Writing Copying

Problem- Based History: Alcohol Abuse

Interpersonal Violence Questions
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Interpersonal Violence Questions If the patient answered “yes” during earlier screening questions about interpersonal violence, follow up in private. You are asked about violence because so many women (men) are dealing with this in their homes: If abuse is a problem for you, you may talk to me about it safely. Are you in a relationship in which you have been hurt or threatened?

Interpersonal Violence Questions
Nobody deserves to be afraid in their home: Has your partner destroyed things you care about? Has your partner ever threatened or abused your children? Has your partner ever forced you to do something you did not want to do? Has your partner prevented you form leaving home, seeing friends, getting a job, or continuing your education? Do you have guns in the home?

Physical Exam Part of General Assessment & History: Clean hands
Observe posture and movement Notice changes in voice tone, rate of speech, perspiration, and muscle tension or tremors Measure blood pressure Palpate pulse for rate Observe and count respiratory rate and breathing pattern Observe eye movement and pupil size

Age-Related Variations: Infants, Children, and Adolescents
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Age-Related Variations: Infants, Children, and Adolescents Variations for neonates and infants include asking about drug and alcohol use of the mother during pregnancy. Children are asked about experiences in school, if they like school, if they get into trouble, and fears about any aspects of their lives. Adolescents are asked about school experiences, drug and alcohol use, and feelings of depression or anxiety; assessing the self-esteem of those in this age group is important.

Age-Related Variations: Older Adults
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Age-Related Variations: Older Adults Indications of depression in older adults may be misinterpreted as expected manifestations of aging: Decrease in appetite or fatigue may be a decrease in metabolism or a loss of taste buds. Problems concentrating or sleeping may be interpreted as expected change of advanced age. Many think depression will go away without intervention, that they are too old to get help, or that reporting sadness may be seen as a sign of weakness.

Cognitive Disorders: Delirium
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Cognitive Disorders: Delirium Delirium is characterized by disturbance of consciousness and rapidly developing change in cognition. Manifestations are 1 or more weeks. Reversible with treatment. Clinical findings: Altered level of consciousness. Impaired memory. Fluctuating attention span. May have hallucinations or delusions. “Sundowning” may increase. Speech may be rapid, inappropriate, or rambling.

Cognitive Disorders: Dementia
Dementia is characterized by memory impairment: Aphasia Apraxia Agnosia Disturbance of executive function Dementia is not reversible. Clinical findings: Onset slow Consciousness intact but memory, judgment, and calculation impaired Flat affect May have delusions Speech is slow and incoherent

Question 1 After completing a dressing change and tidying up the room, the nurse asks the patient if she needs anything. The patient responds, “I am just tired of being tired. Ever since my husband died, I can’t seem to sleep more than 3 to 4 hours a night. I can’t find anything fun to do, and all my friends seem to have disappeared.” The nurse discloses this information to the social worker and recommends that the patient: Start taking diphenhydramine at bedtime. Be assessed on the Beck short form. Undergo AUDIT assessment. Undergo CAGE assessment. Correct Answer: B Rationale: The Beck short form is used to screen for depression. The nurse could talk with a nurse practitioner or physician about a sleep aid, but further assessment is needed. The AUDIT and CAGE tests are used to assess for alcohol use. 35

Chapter 9 Skin, Hair, and Nails

Tissue Integrity Concept represents structural intactness and physiologic function of tissues and conditions that affect integrity. Tissues referred to: Skin, hair, and nails. Interrelated concepts: Perfusion Oxygenation Motion Tactile sensory perception Elimination Nutrition Pain Tactile Perception Motion Perfusion Oxygenation Nutrition Elimination Tissue Integrity Pain

Anatomy and Physiology
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology Integumentary system: Skin and accessory structures Hair Nails Sweat glands Sebaceous glands Skin considered a body organ, an elastic, self-regenerating cover for entire body Primary functions Protects the body from invasion. Protects internal body structures from physical trauma. Helps retain body fluids and electrolytes. Produces vitamin D. Helps regulate body temperature.

A&P: Layers of Skin Composed of three functionally related layers:
Epidermis Dermis Subcutaneous layer (hypodermis)

Anatomy and Physiology: Epidermis
Thin, outermost layer of skin composed of stratified squamous epithelium: Is avascular. Stratum germinativum (or Stratum basale) is deepest layer Stratum corneum is outermost aspect of epidermis Stratum germinativum (or Stratum Basale) is deepest layer: Lies adjacent to rich supply of blood of dermis. Site of active cell generation. As new cells are produced, they push older cells toward skin surface where they begin to die and undergo process keratinization, causing cells to become flat, hard, and waterproof. Stratum corneum is outermost aspect of epidermis: Composed of 30 layers of dead, flattened, keratinized cells. Exposed layer serves as protective barrier and regulates water loss. Dead cells are continuously sloughed off and replaced by new cells moving from the underlying epidermal layers. Process takes about 30 days. Contains melanocytes that secrete melanin: Provides pigment. Shields from ultraviolet radiation.

A&P: Dermis Dermis made up of highly vascular connective tissue.
Thickness varies from 1 mm to 4 mm. Blood vessels dilate and constrict in response to heat and cold, and to internal stimuli of anxiety or hemorrhage, resulting in regulation of body temperature and blood pressure. Dermal blood nourishes epidermis. Also contains sensory nerve fibers for touch, pain, and temperature. Arrangement of connective tissue enables dermis to stretch and contract with body movement.

Anatomy and Physiology: Subcutaneous Layer
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Subcutaneous Layer Subcutaneous tissue (hypodermis) is not actually skin tissue, but a support structure for dermis and epidermis. Acts as anchor for upper layers. Composed primarily of loose connective tissue interspersed with subcutaneous fat. Fatty cells help retain heat and provide protective cushion, and calories.

Anatomy and Physiology:
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Hair, nails, and glands (eccrine sweat glands, apocrine sweat glands, and sebaceous glands) are considered appendages. Structures formed at junction of epidermis and dermis.

A&P: Integumentary Appendages: Hair
Hair formed from epidermal cells in the dermis Each hair consists of: A root A shaft A follicle (the root and it’s covering) Base of follicle contains: Papilla A capillary loop Melanocytes provide color.

A&P: Integumentary Appendages: Nails
Nails are epidermal cells converted to hard plates of keratin: Composed of a free edge Nail plate Nail root (site of nail growth) The white crescent-shaped area at base, the lunula, represents new nail growth. Paronychium is tissue adjacent to nail. Cuticle is epidermal tissue (stratum corneum) growing on nail plate at nail base. Tissue directly under nail is highly vascular and provides clues to oxygenation status and blood perfusion.

A&P: Integumentary Appendages: Eccrine Sweat Glands
Eccrine sweat glands regulate body temperature by water secretion through skin’s surface. Distributed almost everywhere throughout skin’s surface: Greatest numbers on palms of hands, soles of feet, and forehead.

A&P: Integumentary Appendages: Apocrine Sweat Glands
Apocrine sweat glands are much larger and deeper than eccrine glands. Found only in axillae, nipples, areolae, anogenital area, eyelids, and external ears.

A&P: Integumentary Appendages: Sebaceous Glands
Sebaceous glands secrete lipid-rich substance, sebum, which keeps skin and hair from drying out. Greatest distribution found on face and scalp; although found in all areas of body except palms and soles Sebum secretion, stimulated by sex hormone activity, varies throughout lifespan.

Present Health Status Do you have any chronic illnesses? Do you take any medications? What do you take, and how often? Have you noticed changes in the way your skin and hair look or feel? Any changes in sensation of your skin? What kind of work do you do? To your knowledge, are you exposed to any chemicals at home or work?

Past Health History and Family History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Past Health History and Family History Have you ever had problems with your skin such as skin disease, infections involving skin or nails, or trauma involving skin? Has anyone in your family ever had skin-related problems such as skin cancer or autoimmune-related disorders such as systemic lupus erythematosus?

Problem-Based History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History Pruritus is most commonly reported symptom of skin disease. Other common problems related to skin: Rashes Pain/discomfort Lesions Wounds Changes in skin color or texture, hair, or nails Complete symptom analysis: OLD CARTS

Problem-Based History: Pruritus
When did itching first start? Did it start suddenly or over time? Where did it start? Has it spread? Does anything make itching worse? Does anything relieve it? What have you done to treat it yourself? What were the circumstances when you first noticed itching? Taking any medications? Contact with possible allergens such as animals, foods, drugs, plants? Do you have dry or sensitive skin?

Problem-Based History: Rash
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Rash When did rash start? Describe what it looked like initially: flat? raised? How long has rash been present? Does it itch or burn? What makes it better? Worse? What have you done to treat it? Have you noticed other associated symptoms such as joint pains, fatigue, or fever? (recent Strep throat?) Do you have any known allergies? Does anyone else in your family have a similar rash? Have you been exposed to others with a similar rash?

Problem-Based History: Pain/Discomfort of Skin
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Pain/Discomfort of Skin Describe pain or discomfort: When did pain start? Where is it located? Does pain stay on skin surface, or go deep inside? Describe pain or discomfort—sharp, dull, achy, burning, itching: How bad on a scale of 0 to 10? Is pain constant, or does it come and go? What triggers pain? What makes it worse? Better?

Problem-Based History: Lesions or Changes in Moles
Describe lesion you are concerned about. Where is lesion? When did you first notice it? Do you have any symptoms associated with lesion such as pain, discomfort, pruritus, or drainage? Describe changes you have noticed in mole: Color Shape Texture Tenderness Bleeding Itching

Problem-Based History: Change in Skin Color
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Change in Skin Color Has there been any generalized change in your skin color? Yellowish tone? Paleness? Have there been any localized changes in your skin color? Redness? Discoloration of one or both feet? Areas of bruises or patches? Vitiligo is loss of pigmentation in skin.

Problem-Based History: Skin Texture
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Skin Texture In what way has the texture of your skin changed? Thinning Fragile Excessive dryness Do you have excessively dry (xerosis) or oily (seborrhea) skin? Seasonal, intermittent, or continuous? What do you do to treat it?

Problem-Based History: Wounds
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Wounds Where is the wound located? What caused the wound? How long have you had it? Do you have associated symptoms such as pain or drainage? What have you done to treat the wound? Do you typically have problems with wound healing?

Problem-Based History: Hair
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Hair What changes or problems with your hair are you experiencing? When did you notice the changes? Did the changes occur suddenly? Can you think of any contributory factors? Have you recently experienced stress? Fever? Other illness? What kinds of hair products were used on your hair recently? Have you changed diet in the last few months? Have you noticed any changes in distribution of hair growth on your arms or legs?

Problem-Based History: Nails
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Nails What kind of problem or changes do you have with your nails? When did you first notice changes? Have you been exposed to chemicals at home or work? Are your nails brittle? Notice a pitting pattern to nails? Have you ever had an infection of the nail or around the nail bed? Do you chew your nails? Do you have difficulty keeping nails clean? Do your nails appear dirty?

Examination: Skin - Routine
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Examination: Skin - Routine Routine techniques: Inspect for general color and uniformity of color. Consistent over body surface except vascular areas. Whitish pink to olive tones to deep brown. Sun-exposed skin is darker. Note color, pigmentation, vascularity, bruising, lesions, discolorations, or unusual odors. Systematically inspect and palpate skin from head and neck to trunk, arms, legs, and back. Provide adequate lighting so that subtle changes are not missed.

Examination: Skin – Routine
Inspect skin for localized variations in color: Intentional: Tattoos, coining patterns. Normal localized variations: Pigmented nevi (moles), freckles, patches, striae (stretch marks secondary to weight gain or pregnancy).

Examination: Skin Palpation
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Examination: Skin Palpation Palpate skin for texture, temperature, moisture, mobility, turgor, and thickness. Texture: Smooth, soft, intact, even surface, with calluses on hands, feet, elbows, and knees. Temperature and moisture: Warm and dry. Mobility and turgor: Should move easily when lifted, with immediate return after released. Thickness: Varies with age and area. Palms and soles thickest. Eyelids thinnest. Callus: Thick from friction and pressure.

Examination: Hair Inspect and palpate scalp and hair for surface characteristics, hair distribution, texture, quantity, and color. Surface characteristics: Smooth without flaking, scaling, redness, or lesions. Should be shiny and soft. Quantity and distribution: Balding patterns and hair loss; male patterned. Inspect facial and body hair for distribution, quantity, and texture.

Examination: Nails Inspect for nails for shape, contour, color, consistency, thickness, and cleanliness. Edges: Smooth and rounded. Contour: Flat and slightly rounded. Consistency: Note grooves, depressions, pitting, and ridges. Color: Pink, blanched in light-skinned patients; yellow or brown with vertical lines in dark-skinned patients. Thickness: Smooth, uniform.

Age-Related Variations: Infants and Children
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Age-Related Variations: Infants and Children Assessment of skin among infants and children follow same general principals as described for adults. Skin lesions common to infants and children include: Milia Erythema toxicum Diaper rash Rashes associated with allergens

Age-Related Variations: Adolescents
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Age-Related Variations: Adolescents Acne is the most common and worrisome skin lesion common to adolescents because of increases in sebaceous gland activity. Lesions are not only painful, but may also worry patient because of personal appearance.

Age-Related Variations: Older Adults
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Age-Related Variations: Older Adults Skin and hair undergo significant changes with aging. Lesions are commonly found on older adults. Although many lesions are considered expected variations associated with the aging process, incidences of skin cancer increase with age.

Patients with Limited Mobility: Hemiplegia, Paraplegia, Quadriplegia
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Patients with Limited Mobility: Hemiplegia, Paraplegia, Quadriplegia Patients with limited mobility are at risk for skin breakdown. Secondary to pressure and body fluid pooling because of inability to feel pressure or decreased ability to change position to relieve pressure. Examine patient’s skin, especially over bony prominences, and turn patient so that complete skin assessment may be performed. Patients who operate wheelchairs are at high risk for developing hand calluses; care should be taken to examine patient’s hands.

Patients with Limited Mobility: Expected and Abnormal Findings –Skin
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Patients with Limited Mobility: Expected and Abnormal Findings –Skin Assess all contact and skin pressure points for patients who have limited mobility: When a red area of skin is noted, blanch skin by applying gentle pressure over red areas. If skin becomes white when pressure applied and resumes red appearance after pressure relieved, circulation is sufficient and redness will disappear. If skin does not blanch when pressure applied, a stage I pressure ulcer has developed.

Patients with Limited Mobility: Pressure Ulcers
Pressure ulcers are staged: Stage I = Prolonged redness with unbroken skin. Stage II = Partial-thickness skin loss appears as a shallow, open ulcer with pink wound bed. Stage III = Full-thickness skin loss with damage to subcutaneous tissue (may note serosanguineous drainage). Stage IV = Full-thickness skin loss with exposed bone, muscle, or tendon – may have some eschar or slough. Unstagable = Eschar or slough may cover the entire wound bed; thus, it is unstagable.

Common Problems & Conditions: Skin Lesions (txt pgs 111-119)

Macule Flat, circumscribed area Change in color of skin ‹ 1cm diameter
Can not be palpated Examples: freckles, flat moles, petechiae, measles, scarlet fever

Papule Elevated, Circumscribed area Firm Less than 1 cm diameter
Examples: warts, elevated moles, lichen planus, cherry angioma, neurofibroma, skin tag

Vesicles and Pustules Vesicle Pustule Elevated, Circumscribed
Superficial Filled with purulent fluid Less than 1 cm diameter Elevated, Circumscribed Superficial Filled with serous fluid Less than 1 cm diameter

Scars & Keloids Scar Keloid Scar Thin to thick fibrous tissue
Replaces normal skin following injury or laceration to the dermis Example: Healed wound after surgical incision Irregular-shaped, elevated, progressively enlarging scar Grows beyond boundaries of wound

Petechiae & Purpura Petechiae Pupura Flat Tiny, flat
Reddish/purple vasular lesion Non-blanchable discoloration > 0.5 cm in diameter Tiny, flat Reddish/purple vascular lesions Non-blanchable <0.5 cm in diameter

Common Problems & Conditions: Skin
Dermatitis: Variety of superficial inflammatory conditions: Atopic: Superficial inflammation. Contact: Inflammatory reaction to irritant or allergen: Localized erythema. May weep, ooze, or crust. Seborrheic: Chronic inflammation: Scaly, white, or yellowish skin on scalp, eyebrows, ears, axillae, chest, or back. Stasis: Inflammation seen mostly on lower legs of older adults: Areas of scaling, petechiae, and brown pigmentation.

Common Problems & Conditions: Skin
Psoriasis: Usually develops by age 20 years. Slightly raised erythematous plaques with silvery scales. Mostly on elbows, knees, buttocks, lower back, and scalp. Pityriasis rosea: Acute, self-limiting disease of young adults in winter. Thought to be viral.

Common Problems and Conditions: Lesions Caused by Viral Infections
Warts – caused by HPV. Herpes simplex – group of 8 DNA viruses. Outbreaks triggered by sun exposure, stress, fever. Grouped vesicles with an erythematous base. Very painful and highly contagious Eruptions last about 2 weeks Herpes varicella – Chickenpox Lesions erupt in crops Painful and highly contagious Infectivity lasts about 6 days after final eruptions Herpes zoster – Shingles Grouped lesions along sensory nerve line

Common Problems and Conditions: Lesions Caused by Fungal Infections
Tinea infections: Tinea corporis – Ringworm. Tinea cruris – “Jock itch.” Tinea capitis – scaling and balding. Tinea pedis – “Athlete's foot.” Candidiasis: Affect superficial layers of skin and mucous membranes.

Common Problems and Conditions: Lesions Caused by Bacterial Infections
Cellulitis – acute streptococcal or staphylococcal infection of the skin and subcutaneous tissue. Impetigo – highly contagious Group A streptococcal infection. Generally occurs on face, around mouth and nose. Folliculitis – inflammation of hair follicles. Furuncle (abscess or boil) – staphylococcal infection.

Common Problems and Conditions: Lesions Caused by Arthropods
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Lesions Caused by Arthropods Lesions caused by arthropods: Scabies – highly contagious mite Sarcoptes scabiei. Lyme disease – tick infected with Borrelia burgdorferi. Spider bites – majority from black widow or brown recluse spiders.

Common Problems and Conditions: Neoplasms

Common Problems and Conditions: Neoplasms
Basal cell carcinoma – most common: Locally invasive; rarely metastasizes. Nodular pigmented lesions with depressed center and rolled borders. Squamous cell carcinoma: Initially appears as a red, scaly patch. Melanoma – most serious: Malignant proliferation of melanocytes. Irregularly shaped with color variations. Kaposi’s sarcoma: Develops in connective tissue of immunosuppressed. Dark blue-purple macules, papules, nodules, and plaques.

Common Problems and Conditions: Lesions Caused by Abuse
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Lesions Caused by Abuse Bruise (Ecchymosis): Discoloration from blood seeping into tissues resulting from trauma. Bite Burn

Common Problems and Conditions: Hair
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Hair Pediculosis (lice): Lice on the body are called Pediculosis corporis. Pubic lice are called Pediculosis pubis. Alopecia areata: Chronic inflammatory disease of hair follicles resulting in hair loss on scalp. Hirsutism: Increase in growth of facial, body, or pubic hair in women.

Common Problems and Conditions: Nails
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Nails Onychomycosis: Fungal infection of nail plate caused by Tinea unguium. Paronychia: Acute or chronic infection of cuticle caused by staphylococci and streptococci, although Candida may be causative organism. Ingrown toenail: Occurs when nail grows through lateral nail and into skin. Usually involves great toe.

Question 1 As the nurse performs a respiratory assessment, he notes a mole on the patient’s back over the right scapula. What is most important for the nurse to ask the patient? “Do you sleep on your right side?” “Does your bra strap rub this mole?” “Has this mole changed recently?” “Have you applied any creams to this mole?” Correct Answer: C Rationale: Although moles can become irritated with certain habits or by clothing, it would be more important for the nurse to ask about recent changes. A recent change could be an indication that a malignancy is present. 91

Question 2 A pustule is noted over the maxilla of the patient. Which of the following illustrates a pustule? A. B. Correct Answer: B Rationale: “A” displays wheals of urticaria. “C” displays keloids. “D” displays a blister. C. D. 92

Question 3 An 82-year-old patient is brought to the emergency department with suspected broken right hip. It is believed that she was lying between the bed and the wall for more than 48 hours before she was found. As the nurse conducts an assessment, the following condition over the lower back or coccyx area is seen. What should the nurse document related to this finding? Ecchymosis over coccyx Scaling lesion with exudate over coccyx Stage 2 pressure ulcer Stage 4 pressure ulcer Correct Answer: C Rationale: Ecchymosis refers to bruising. Scaling refers to dry skin, and exudate is a fluid that is weeping from a wound. This wound does not appear to have any weeping. Stage 2 pressure ulcers include loss of the epidermis; a stage 4 pressure ulcer will include loss or damage to muscle, bone, or both. 93

Case Study 1 Silas is a 2-year-old male child who attends day care. He has eight siblings at his home. All of his immunizations are up to date. He has a history of strep throat and RSV. His favorite activity is block stacking. His mother reports that he is generally a happy baby who is starting to become potty trained.

Case Study 1 (contd.) Subjective data: Complains of painful rash on R calf that is spreading to lower legs. Mother says the rash has been there for 1 week. Mother admits to trying oatmeal baths to stop the pain, but says this has not helped. Objective data: Vital signs: T 96.4; P 71; R 14. Height: 2’0. Weight 40 lb. R calf has a dime-sized, honey-crusted sore. R calf has become increasingly more irritated over the past week.

Case Study 1 (contd.) Questions: What risk factors does Silas have for impetigo? What measures might have helped prevent impetigo? What should the nurse do in this clinical situation? Prioritize actions. Risk factors present for Impetigo are: Attending day care. Having multiple siblings in the home. What measures might have helped to prevent impetigo? Instruct parent on proper cleansing of skin on a daily basis. Instruct parent to discuss cleaning protocols with the school. Wash all bed linens in hot water. Appropriate actions in this situation would be as follows: Assess for patient and familial understanding of teaching. Include his siblings in the proposed interventions and plan. Assess for medicine compliance. Make sure family and school understand the importance of hand washing.

Case Study 2 Sidney is a 4-year-old male child, who attends preschool. He has five siblings at his home. All of his immunizations are up to date. He has a history of otitis media and RSV. His favorite activity is sandbox play. He reportedly plays most of the day in the sandboxes at school.

Case Study 2 (contd.) Subjective data: Complains of itching, circular, rash behind his left ear. Mother says the rash has been there for 4 days. Mother admits to trying Vaseline to stop the itching, but says this made it worse. Objective data: Vital signs: T 97.2; P 68; R 16. Height: 4’0. Weight 70 lb. L ear rash has classic ring-worm shape with scaly appearance that spreads to his hairline. No drainage. The rash is quarter sized.

Case Study 2 (contd.) Questions: What risk factors does Sidney have for Tinea capitis? What measures might have helped prevent Tinea capitis? What should the nurse do in this clinical situation? Prioritize actions. Answers: Risk factors present for tinea capitis are: Attending preschool. Having multiple siblings in the home. Playing in sandboxes and dirt at school daily. What measures might have helped to prevent Tinea capitis? Instruct parents on proper cleansing of scalp and skin on a daily basis. Instruct parents to discuss cleaning protocols with the school. Keep other children in the home from sharing hair-related items. Wash all bed linens in hot water. Appropriate actions in this situation are as follows: Assess for patient and familial understanding of teaching. Include his siblings in the proposed interventions and plan. Assess for compliance with taking medicines.

Lecture 3 K. Hendrickson PhD, RN Fall 2013

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Lecture 3 K. Hendrickson PhD, RN Fall 2013

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