Health Assessment

Blueprint for Exam #1

Chapter 1:
Types of Assessment ie initial comprehensive assessment, etc.
Initial: subjective, objective; ROS, history, Lifestyles/health practices
Ongoing/Partial: occurs after database est.; Reassessment; readmitted for the same problem
Focused/problem-oriented: performed in relation to a specific health concern; what is the
current problem
Emergency: VERY rapid; performed in life-threatening situations
o Ex) weakness on one side, cardiac arrest
Nursing Process
Assessment: collect data
o Prepare for the assessment
o Collect subjective/ objective data
o Validate the information
o document
Diagnose: analyze data; make dx
Planning: plan of care; determine outcomes; what is the goal and timeframe
Implement: carrying out the plan; monitor
Evaluate: assess whether outcomes has been met; revise if necessary
Difference between medical and nursing assessment
Medical dx: looks at the pathological cause/ disease
Nursing dx: looks at the response to the health status; look at the functional ability of the pt
Chapter 2:
Interviewing phases
Introduction:
Purpose; who you are, what is occurring, what is your role; INTRO; let pt know you will be
taking notes
Confidentiality; make pt comfortable; environment private
Develop trust and rapport
Working SUBJECTIVE DATA
Getting the information from the actual interview
Documentation: health insurance, beliefs, understandings, family contact
Reason for seeking care; Hx of present health concern
PH, FH, ROS, Lifestyles/health practices
Summary/Closing
Summarize info: this is what you told me
Validates problems and goals; ID possible plans
Q&A; agreement to information, plan, objectives
Communication/Interview skills verbal and nonverbal effective and ineffective
Effective: - one question at a time
Active listener: pay attention, face the patient, sit during interview, maintain eye contact; look
interested
Guided questioning
Open ended questions
Graded questions: how many/how much-range of amount
Multiple choice questions: is the pain sharp or dull; is it constant or intermediate (this may
min. the pt responses/ max distorted information)
Clarify: ask pt to clarify something you may be unsure about
Encouragement: uh huh: look at them when they are speaking- take notes of importance
Reflection: pt responds: pain got worse and spreading now
Nurse responds: spread? --> use the pts language; what do you mean by.

Health Assessment
Nonverbal communication: posture, facial expressions; your behavior during the interview
Empathetic responses: NOT: I am sorry about your moms death; YES: It must be very
heartbreaking for you.
Validation: acknowledge what is occurring; ask about how the patient feels
Reassurance: it is okay to feel like this when a patient feels angry or in denial
Summarization: this is what the pt told the nurse; how the nurse interprets it; pt should correct the
nurse if needed
Transitions: now I am going to ask you questions about...
Empowering the patient: nurse encourages pt to feel in control; help pt deal w/ situation; EXPLAIN
everything
Ineffective:
Do not use LEADING questions: it did happen to you yesterday, right?
False assurance: everything will be okay
Unwanted advice: do not give advice
Using authority: sounding like you are demanding the pt
Use of Avoidance lang.:
Engaging in distancing:
Professional jargon: explain in laymen terms unless pt is capable of understanding
Talking too much/interrupting
Using why questions
How/when to use different types of questions
Open-ended: What happened today; tell me what the problem is
Closed-ended: did this happen to you yesterday?
Laundry list: choice of words to choose from
Rephrasing: clarify the information the client is providing
Well-places phrases--> encouragement skill: yes, I see; I agree
Inferring: do not lead rather get more information: it seems you have more difficulty w/ your ;
use the pts words
Providing information: answer every question the pt; be honest if do not know the answer
Focus question: more specific toward the problem: So you woke up short of breath; has this
happened before?
How to deal with anxious, angry, depressed, manipulative patient
Anxious
Structure info
Explain who you are, your role, and purpose of visit
Questions = simple/concise
Nurse needs to stay Relax
Do not hurry; decrease external stimuli
Angry
Calm, in-control mannerisms and tone
o Let patient vent
o If excessive, do not touch or argue back
Obtain info from other health professionals as much as needed
Do not argue back; provide personal space
Depressed
Show interest and understanding to client and situation
Do not be upbeat or encouraging
Manipulative
Provide structure and limitations
Fine line b/w manipulative and reasonable requests
What constitutes as subjective data
ANYTHING elicited by the patient; must be verified by the patient

Health Assessment

ROS for current health problem: need to ask about the specific systems
Lifestyle and Health practices:
o Nutrition/ weight management: meals of the past 24 hrs
--Self-concept/self
care/relationships
o Activity level/exercise/ social activities
-- values and beliefs
o Sleep and rest: naps?
-- edu/work; stress
levels/coping
o Medication and substance use/ herbal preps
Complete Health History
Biographical data
--FH
Reasons for seeking health care
--ROS
Hx of present health concern
--Lifestyle and health practices
PH
--Developmental level
COLDSPA
Character: description
-- Severity
Onset
-- Pattern: what makes it better/worse
Location
-- Associated Factors: other symptoms
Duration
Chapter 3:

How to prepare for a physical exam examiner, patient

Prepare physical setting: get equipment, room is comfortable and warm, private and quiet, firm
exam bed/table
Prepare self: be calm, confident, practice clean/sterile technique, wash hands, use protective
gear
Approach/prepare pt: est. rapport, respect clients requests and desires, get consent, and
explain everything
Positioning Client
1. Sitting
a. Can evaluate head, neck, lungs, chest, back, breasts, armpits, heart, vital sign, arms
2. Supine
a. Flat on back, Legs together
b. Evaluate head, neck, chest, breast, armpits, abdomen, heart, lungs, limbs, peripheral pulses
3. Doral recumbent
a. On back, knees bent, legs separated, feet flat
b. Most comfortable for people with back or abdomen pain
c. Assess: head, neck, chest, armpits, lungs, heart, limbs, breasts, peripheral pulses
4. SIMs position
a. Lay on side; Lower leg behind body and flexed; Upper leg flexed at sharp angle; forward
b. Upper arm bent
c. Assess: rectal and vaginal areas
5. Standing
a. Assess: posture, balance, gait, males genitalia
6. Prone
a. Flat on stomach, head to one side
b. Assess: hip joint, back
c. If cardiac or respiratory problems = do not use position
7. Knee-chest
a. Kneeling, 90-degree angle b/w body and hips; Arms above head; head to one side
b. Assess: rectum
c. Do not use with elderly or pt. with respiratory or cardiac problems
8. Lithotomy
a. Lays on back, hips at end of table, feet in strirrups (at the gyno)
b. Assess: female genitalia, reproductive tracts, rectum

What is objective data

Anything that can be measured: physical characteristics, body functions, appearance/behavior,
measurements

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Physical examination techniques

Inspection: observation
o Note color, patterns, size, location
o Consistency, symmetry, movement, behavior
o Odors, sounds
Palpate: feel/touch
o lightly for surface anomalies
o medium for anomalies under the skin
o deep w/ 2 hands to feel organs
o Texture: rough or smooth
o Temperature: warm or cold
o Mobility: fixed/movable/still/vibrating
o Consistency: soft/hard/fluid filled
o Strength of pulse: strong/weak/thready/bounding
o Size: small, med., large
o Shape: well defined or irregular
o Degree of tenderness
Percussion: make vibrations to
o Elicit pain, reflexes
Pain: Ex) sinuses: if they hurt= inflamed
Reflexes
--> direct: finger
--> indirect: two fingers
--> blunt: flat hand on body location, other fist hits flat hand
Ex) feeling the kidneys
o Determine location, size, shape, density of organs; detect abnormal masses
Organs: Ex) percussion over the liver
o Sounds
Lungs --> resonance/vibration: normal; hyperresonance/excessive vibrations: air
filled (COPD)
Abdomen --> Tympani; dullness= solid tissue Ex) SPLEEN, LIVER
Bones --> flatness
Auscultation: listening
o Intensity: loud or soft
o Pitch: high or low
o Duration: length
o Quality: musical, crackling, raspy
Stethoscope: diaphragm for high pitched sounds (heart, breaths, bowel)
Bell for low pitched sounds or bruits (abnormal loud, blowing, murmuring sounds)
Chapter 4:

Purpose of Validation
Confirm/ verify subjective and objective data
Need to make sure information is correct to cont. with nursing process
Data requiring validation

Health Assessment

Gaps b/w subjective/objective data, what the person says at different points of the
conversation
Findings that are abnormal/ inconsistent w/ other findings
Methods of validation
Repeat assessment
Clarify data w/ client- additional questions
Verify data w/ another healthcare professional
Compare objective findings w/ subjective findings
Missing information
ID areas where more data is needed
o Ex) pt weighs 98lbs: want to know if pt has lost weight or this has been normal for
some time
o Ex) pt tells you he lives alone: want to know if he has a support group, ability to
function alone
Documentation
Purpose:
Chronological source, prevents repetition, helps w/ dx,, determines edu. & teachings,
eligibility for reimbursement, legal record
What do you document:
Subjective/ Objective data: sub- if there is nothing write DENIED
Present health concern via COLDSPA
Follow health hx: PH, FH, lifestyle/health practices
Guidelines:
Legible w/ non-erasable ink or print; correct grammar/spelling; Abbreviations approved by
institution
Wordiness will create redundancy
Phrases not sentences
Record findings not method of obtaining; what you see; judgment free
Record pts understanding and response to info/tx
Do not use normal
Chapter 5:

Analyze data
Critical thinking
o ID abnormal data and strengths of pt
o Cluster data
o Draw inferences
o Purpose possible nursing dx check for defining characteristics; confirm/rule out dx
o Document conclusions
Similar to ADPIE
o Assess areas of concern and strengths
o Dx based on abnormal findings and pts abilities
o Plan what outcomes and expectations via the dx; implement plan
Interventions come from the problem
o Evaluate and document

Health Assessment
Chapter 6:

Mental status
Ones orientation and consciousness
o Orientation: person, place, time, situation looking for cognitive consciousness
Orientation to time is the 1st to be lost
Orientation to person is the 2nd to be lost
Mental Health assessment
o Observe the pt; ask them questions
How to assess dementia, delirium
Looking for Dementia

Mini Mental
Not early
dementia
Test for dementia;
outdated- not
preferred
Use when pt is
disoriented

No Executive
Functioning

No consideration
for age, culture

SLUMS
Early Dementia
Considers edu.
level, language,
age
Executive
functioning

Montreal
Considers edu
level
Early signs of
Alzheimers
dementia

Executive function

Mild cog
impairment

Spatial component

CAM
Acute onset
Inattention
Disorganized
thinking
Altered level of
consciousness
Based on
OBSERVATION
Talk w/ pt; observe
attentiveness;
thought process;
confusion;
consciousness
IDs DELIRIUM

Alzheimers Guide
All Alzheimer is dementia; not all dementia is Alzheimer
Lose executive functioning
Repeatedly ask the same questions
o Pt consistently asks the same questions about the same topic/situation
o Caregiver/families need to constantly remind pt how and what to do
lost/disoriented to places and of time; cannot follow directions
Do not recognize family
Difficulty performing routine tasks
Neglects personal hygiene
CANT RECALL RECENT EVENTS; remembers remote events
Dementia vs. Alzheimer
Dementia
Not consistent memory lost of recent information- more forgetfulness
Pathological process that can be fixed; cause of the forgetfulness
o Ex) Thyroid problem; kidney failure; diabetes can CAUSE the pathological process
of forgetting
Alzheimer
Dont remember anything of recent memory; consistent recent memory loss

Health Assessment
Chapter 7:
General Survey
Apparent state of health: general observation for acute (focused assess.) or chronic illness (full
assess.)
Level of consciousness: stages of consciousness
o Alertness: speaking to pt in normal tone

eyes are open, pt looking at you, responds fully and appropriately

o Lethargy: Speaking to pt in loud voice-call pts name; how are you
Pt= drowsy; eyes open; looks at you; responds to questions but then falls asleep
after
o Obtundation: (dull) speak in loud voice; shake pt gently
Pt opens eyes and looks at you; responds slowly; somewhat confused
Alertness and interest in environment = decreased
o Stupor: (dazed state; unconscious) Apply painful stimuli
Arouses ONLY from PAINFUL stimuli
Verbal responses are slow/absent
Lapses into an unresponsive state when stimulus stops
Minimal awareness of self or environment
o Coma: Apply repeated painful stimuli
Remain unaroused w/ eyes closed; no evident response to inner need or external
stimuli
1. Decorticate rigidity: arms flexed tight to body; legs extended; rotated
inward- corticospinal issue
2. Hemiplegia: sudden unilateral brain damage; one side is paralyzed
3. Decerebrate rigidity: jaw clenched; neck extended; arms adducted stiff;
wrist flex diencephalon, midbrain, pons
Facial expressions: eye contact, facial movements
o Parkinsons Disease- pt has a masklike facial expression
Odors of the body or breath
o Fruity scent = diabetes is out of control
o Alcohol?/ Marijuana?
Personal hygiene/dress: appropriate? Clues to weight loss; cleanliness?
o Can get cold easier as you age- less body muscle
Posture, gait, motor activity
o Stooped over posture (-); straight/upright posture (+)
o Walking heals to toes and swinging arms? (+)
o Facial muscles appropriate? Abnormal = twitches, muscle spasms; observe overall
muscle control
Weakness = difficulty in moving muscle; loss of muscle power
Fatigue = you dont feel like doing anything/something; has normal muscle
function
Speech: articulating appropriately; no slurred words/ awkward pauses
Voice and speech problems
o Aphonia: no, voice; loss of voice; from disease affecting larynx (voicebox)
o Dysphonia: faulty, voice; speak in a whisper/ hoarse
can be disease oriented; something affecting larynx or vocal cords = cancer?
1. Laryngitis, laryngeal tumors, unilateral vocal cord paralysis
2. Vagus nerve
o Dysarthria: defect in muscular control; slurred speech MS/ Parkinsons
o Aphasia: disorder of producing or understanding lang.; pathological component/causelesion
Wernickes: can produce language but cannot understand language; cant
process

Health Assessment
1. Production of speech is intact
2. Cannot comprehend, name (temporal lobe)
Brocas: production of lang. impaired; can understand lang.
1. FRUSTRATION enhances problem
2. Not fluent; production of speech highly impaired
3. Comprehension is intact
4. cannot name (although the pt knows what the object is)
5. Frontal lobe
Both cannot repeat or write
Mood and affect: answers and mood are appropriate
o Ex) appropriate: in so much pain and pt is wincing, grimacing, low demeanor
o Ex) inappropriate: in so much pain and pt is laughing
Check vital signs
Height and weight
BMI
Ideal body weight
Determine frame by measuring the wrist- wrist circumference- smallest distance around the
wrist in cm
o Wrist least place to accumulate fat
Female: 100lbs for 5 feet + 5lbs for each INCH over 5 ft --> Medium frame
Subtract 10% for Small frame
Add 10% for Large frame
Ex) Female: 5ft 6in 5ft =100lbs + 5*6in= 30lbs
130lbs for a 56 female, medium frame
-10%= 117lbs for 56 female small frame
+10%=143lbs for 56 female large frame
Ex) Female 411 95lbs (subtract 5lbs from the 5ft total (100))
Male: 106lbs for 5 feet + 6lbs for each inch over 5ft --> medium frame
Subtract 10% for small frame
Add 10% for large frame
Ex) Male: 5ft 6in 5ft= 106lbs + 6in=36in (6*6)
142lbs for a 56 male, medium frame
127lbs for a 56 male, small frame
156.2lbs for a 56 male, large frame
Percentage of ideal body weight
o

Actual weight
100= of IBW
ideal body weight

Ex) Actual weight: 130lbs

Ideal body weight: 100+5=
105lbs

Ideally you want to get close to 100%

o 100-110% = normal
o > 120% = obese
o >110% = overweight
o 80-90% = lean and potentially malnourished
o 80-70%= moderate malnourished
o <70% = severely malnourished
Overweight people:
o Higher Triglycerides
o Higher blood sugar
o What is activity level? Smoker?
o Increase weight, increase risk for osteoarthritis, respiratory problems, sleep apnea,
stroke

Health Assessment
BMI + categories
BMI < 18.5 (underweight)~18 or less
BMI = 18.5 to 24.9 (normal) ~ 18 to about 25
BMI = 25-29.9 (overweight) ~ 25 to about 30
BMI > 30 = obese ~ 30s
BMI: 40+ extreme obesity ~ 40 +
Waist circumference
Pt stands straight feet together, arms at side; measure snugly around waist at belly button
Pt should be relaxed, taking normal breaths
Record on exhalation
Female normal waist circumference = < 35 inches; over 35 = overweight
Male normal waist circumference = < 40 inches; over 40 = overweight
Chapter 13:
Subjective data of skin, hair, nails: Symptoms, PH, FH, Lifestyles/Habits
Skin:
Skin problems, swelling, color change; birthmarks/moles; change in pain, pressure, touch, temp.,
body odor
Shots, hx of lesions, tattoos piercings, past treatments on skin, allergic reactions
Cancer: eczema, psoriasis, melanoma; keloids
Bathing patterns, type of soap, how often; sunbathe; environmental exposure; sedentary life; self
exam?
Color Influenced by illness, body temp, pregnancy, genes, arterial blood flow, O2, liver function,
melanin
Hair:
Hair loss, change in condition of hair
Hair loss in past, lacerations to the scalp
Hair care routine, products, color treatment
Nails
Change in condition and appearance of nails
Infections of nails
Who cleans them; how are they cleaned; salon use sterile procedure
How to perform the physical exam for skin, hair, nails
o Strong direct lighting- skin assessment
o Tangential lighting- side light for eyes (penlight)
o Gloves and centimeter ruler

Health Assessment
Normal & Abnormal findings for physical exam of skin, hair, nails
Skin
Inspection/Palpate
1. General skin coloration + odor
a. Normal: even colored skin tones
i. Older people pale skin decrease melanin produced/ dermal vascularity
b. Abnormal:
i. Pallor: loss of color
1. O2 deficiency, decrease hematocrit
Anemia, shock
ii. Cyanosis: white skin blue-tinged
1. Central cyanosis (areas near the heart): cardiopulmonary problem
Look at oral mucosa
2. Peripheral cyanosis: localized; vasoconstriction, exposure to cold
Look at extremities
iii. Jaundice: yellow skin tones
1. In sclera (whites of eyeball), oral mucosa, palms, soles
Hepatic (liver) dysfunction
iv. Erythematic: Redness of skin
1. Increased blood flow, increased RBC in area, infection
o
o
o
o

white patches (vitiligo- cow patches)

Abnormal= rash: red ex) butterfly rash across nose and cheeks =Lupus erythematosus
Litchentification= thickened skin- looks like dry pussy skin
Fungus: under ultraviolent light fluoresce blue-green
c. Body odor
i. Abnormal
1. Strong odor sweat gland disorder, poor hygiene- need teachings
2. Temperature: use dorsal surface of hand
a. Abnormal
i. Cold skin- shock, hypotension
ii. Cool skin arterial disease
iii. Very warm skin febrile state, hyperthyroidism (increased movement)
3. Moisture: use dorsal side of hand
a. Normal: appropriate amt of moisture
i. Older people- dryer skin - decrease sebum (oil) production
b. Abnormal:
i. Increased moisture, diaphoresis (SWEATING) fever, hyperthyroidism
ii. Decreased moisture- dehydration, hypothyroidism (slowww)
iii. Clammy skin shock, hypotension
4. Texture- light touch
a. Abnormal:
i. Rough, flaky, dry skin hypothyroidism
1. Obese people usually complain of dry, itchy skin
5. Thickness
a. Normal: normally thin w/ potential calluses in areas constantly exposed to pressure
b. Abnormal:
i. VERY thin arterial insufficiency; steroid therapy
6. Edema: thumbs to press down on skin or feet and ankles
a. Edema: swelling related to accumulation of fluid in the tissue
ii. Normal: skin rebounds; does not remain indented when pressure is released
iii. Abnormal:
1. Indentations on skin
7. Mobility and turgor
a. Mobility: how easily the skin can be pinched
b. Turgor: skins elasticity; how quickly does skin return to original shape
c. Normal: easily pinched, returns to place immediately
iv. Older people: decrease in turgor- decrease elasticity & collagen fibers =
saggy/wrinkled skin

Health Assessment
d. Abnormal:
v. decreased mobility edema
vi. Decreased turgor slow return of the skin dehydration
8. Lesions: Size, Shape, Color, Texture, surface relationship, exudate, tenderness, body
location
(Sam Sells Coats to SET B)
a. Normal: smooth- no lesions; stretch marks, healed scars, freckles, moles, birthmarks
i. Look around skin folds
ii. Older people: common skin lesions- senile keratoses (small, raised, dark sun
exposed area)/lentigines (flat ?,darker sun exposed skin), cherry angiomas,
purpura, cutaneous tags
b. Abnormal
i. Local or systemic lesions
1. Primary: arise from normal skin due to irritation or disease
Size: less than 0.5 cm - usually
Shape: Macules/ Patch- flat (</> 1 cm); Wheal- elevated, red (2cm)
Vesicle/ bulla- blister/fluid filled (</> .05)
Color: Pustules- white/yellow-white & pus filled
Petechia: red, round, macule (flat <1cm); flat; bleeding from superficial capillaries
Purpura: red to purplish
Texture: macules- smooth; warts- rough; psoriasis- scaly
Surface location: flat nonpalpable macules/patches, purpura, ecchymoses (>petechia), spider
angioma
Raised palpable solid- papule/plaque (</>.5), nodules/tumor (.5-2/>2 cm), wheals
Raised palpable cystic- vesicles/bullea, pustuale, cyst
Depressed: atrophy, erosion, ulcer, fissures
Pedunculated (having a stalk): skin tags
Exudate: Serous: clear/white/pale (GOOD)--> vesicles/bullea (blister)
Purulent: gross, infected, a lot, colorful; Pus: yellow --> acne, impetigo
Tenderness: bullae or bruise- underlying cause/ pain
Body Location: where is it on the body
Configuration of lesion:
Annular/circular: in a ring shape--> ringworm
Round/oval: coin shaped --> eczema
Confluent: runs together --> rubella
Discrete: separate; apart; isolation; no association w/ another --> moles
Grouped: cluster; individual entities but grouped together --> herpes
Gyrate: twisted/coiled; worm like --> gyrate erythema (twisted red skin)
Target/iris: concentrated rings of color; bulls eye like --> lyme disease
Linear: line, streak, stripe --> poison ivy/ herpes zoster (shingles)
Polycyclic: annular lesions growing together; slowly growing into one nearby; distinct w/ little
grouping
Zosteriform: linear growing on nerve root; never crosses midline
always stays on one side; can cross front to back but not left to right
Distribution of lesions:
Diffuse/generalized: occurring all over --> full body rash; urticaria (skin rash) from allergic
reaction
Scattered: sparsly distributed --> seborrheic keratosis (warts, moles)
Localized: one area of body; discrete area; usually unilateral
Regional: bilateral; one body area --> tinea capitis (skin fungus)
Torso: just on the torso (below neck to below belly button)--> pityriasis rosea (flaky dry skin)

Health Assessment
Extensor surfaces: posterior elbows; anterior knee
Dermatome lines: zosteriform (configuration)- along a nerve root --> herpes zoster (shingles)
Hairy areas: where people grow hair- not scalp --> herpes II (sexual), lice

2. Secondary: lesion change; lose superficial epidermis- moist areas;

rupture vessels
Erosion, ulcer, scar, fissure (linear cracks in skin)
New scars- red and raises; old scars- white or silver --> healed wound
Pressure point areas: Back of the head, shoulder blades, elbows, iliac crest, sacrum, soles/heels
Sitting: behind knee; Laying on side- ear, trochanter, thigh, lower leg, ankles,
knee
Prone- chin, ribs, keep cap, big toe
Braden scale-predict risk: factors that cause ulcer; PUSH tool- assess: what does ulcer look
like
Abnormal: Skin breakdown- red area; progresses to serious and painful pressure
ulcer
Ulcer scale:
I- sores are not open wound
II-skin breaks open, wears away, tender, and painful
III- sore, more pain; extends into tissue beneath the skin; forming small crater
IV- very deep; reaching muscle or bone; extensive damage
3. Vascular: reddish-bluish lesions
Petechia: red, round, macule (flat <1cm); flat; bleeding from
superficial capillaries
Keloid: excessive collagen formation
4. ABCDE rule = for mole and skin cancer assessment
A: asymmetry; B: border; C: color; D: diameter; E: elevation/evolution
Benign moles/skin cancer:
Malignant moles/skin cancer:
Not asymmetric; symmetric all around
asymmetric- two sides do not
match
Borders are even
borders uneven
One color
2 or more colors
Smaller than 0.6inch
larger than 0.6inch
Does not change; relatively flat
changes in size, shape, color,
elevation
Diameter is not important if the preceding steps present (+) for malignancy
Surgery/excising: need 2 in around and 2in deep to remove
5. Skin cancer: primary or secondary
Basal cell carcinoma: most common; 40-80 yrs old
i. Nodule(medium solid), papule (small solid), pearly
border; volcano like- depressed center
Squamous cell carcinoma: 2nd most common; invasive skin
cancer; 50 yrs old; blue eyes/freckles = increase risk
i. At risk with sunbathing
ii. Head and neck
iii. Central ulcer w/ reddened scaly borders; well defined
malignant melanoma: worst form; very dark
Scalp and hair
Inspection and Palpation
1. General color and condition
a. Normal: natural hair color- amt of melanin
b. Abnormal: patchy gray hair nutritional deficiencies
i. African American children severe malnutrition copper-red hair
2. Cleanliness, dryness, oiliness, parasites, lesions (texture and lesions)

Health Assessment
a. Normal: clean and dry; sparse dandruff; hair is smooth and firm- somewhat elastic
i. Aging brings on coarser and drier hair
ii. African Americans: dry scalps; dry, fragile hair; may use oil or Vaseline
product in hair
iii. No lesions
b. Abnormal:
i. Excessive scaliness dermatitis
ii. Raised lesions infections; tumor growth
iii. Dull, dry hair hypothyroidism; malnutrition
iv. Poor hygiene
v. Pustules w/ hair loss in patches = tinea capitis --> ringworm
vi. Infections of the hair follicle- folliculitis pus surrounded by erythema
3. Amt and distribution of scalp, body, axillae, and pubic hair
a. Normal: balding must be symmetrical
i. Older people: thinner hair- decrease hair follicles; decrease in hair w/ aging
1. Alopecia more in men
2. Hair loss moves from periphery of head to center
3. Elder women hair growth on chin hormonal changes
b. Abnormal:
i. Excessive generalized hair loss infection, nutritional deficiencies, hormonal
disorders, thyroid/liver disease, drug toxicity, hepatic (liver)/renal failure;
result of chem/radiation
ii. Patchy hair loss infection of scalp, discoid or systemic lups erythematosus;
chemo
iii. Hirsutism facial hair on females
1. Cushings disease increased facial hair; over production of ACTH by
pituitary
2. Result of imbalance of adrenal hormones; side effect of steroid
Nails
Inspection
1. Grooming and cleanliness
a. Normal: nails are clean and manicured
b. Abnormal:
i. Dirty, broken, jagged nails poor hygiene
1. Could be a hobby biting nails
2. Occupation electrician
2. Color and Marking
a. Normal: pink tones; longitudinal ridging
i. Dark skinned people: freckles or pigmented streaks normal
b. Abnormal:
i. Pale or cyanotic nails hypoxia or anemia
ii. Splinter hemorrhages- trauma
iii. Beaus lines: occur after acute illness/trauma; eventually grow out ridges
iv. Yellow discoloration fungal infections
3. Shape
a. Abnormal
i. Early clubbing- spongy sensation 02 deficiency
ii. Late clubbing- hypoxia- perfectly straight- no normal slant into cuticle
iii. Spoon nails- concave iron deficiency anemia (indentation)
Palpation
1. Texture and consistency
a. Normal: hard; immobile
i. Dark skinned pt: thicker
ii. Older people: appear thickened, yellow, brittle- decreased circulation
b. Abnormal:
i. Thickened especially toenails --> decreased circulation
c. Note if nailplate is attached to nailbed

Health Assessment
i. Normal: smooth and firm; nailplate firmly attached to nailbed
d. Abnormal:
i. paronychia (abnormal nail condition- inflammation) local infection
ii. detachment of plate from bed (onycholysis- nail breakage)
infection/trauma
2. Test capillary refill
a. Press the nail tip briefly and watch for color change
i. Normal: pink tone returns immediately after release of pressure
ii. Abnormal: slow refill respiratory or cardiovascular diseases hypoxia

Health Assessment
Chapter 14:
Subjective data for head and neck: Symptoms, PH, FH, Lifestyle/Health Practices
Frequent headaches: type of headache pain + location, intensity, duration
Dizziness, spinning (vertigo), lightheadedness, loss of consciousness
Neck pain, face pain, limited movement, lumps, bumps, or lesions, changes w/ hair
Skull fractures, surgeries on head or neck, Traumatic Brain Injury, head injuries
Hx of headaches, neck or head cancer in family
Helmet, seatbelt use; stress/tension; level of exercise/energy, sleeping patterns; smoker?; typical
posture?
Head/neck pain interfere w/ work, relationships, daily living?
Cervical lymph nodes
Preauricular: in front of ear
Postauricular: behind ear
Occipital: base of skull
Tonsillar: right under the jaw bone- toward back- below the ear; what you feel when you are sick
Submandibular: middle mandible
Submental: behind tip of mandible (chin)- most anterior
Superficial cervical: superficial to sternomastoid muscle (muscle behind ear to sternum); side
of neck
Posterior cervical: in triangle of the sternomastoid muscle and the trapezius muscle
Deep cervical chain: node line deep in the sternomastoid muscle (inferior)
Supraclavicular: hook fingers over clavicles feel deeply b/w bone and sternomastoid muscles
Palpate: Size/shape, location/distribution (discrete/merged), mobility, consistency, tenderness
Normal: no swelling, enlargement, tenderness, hardness CAN NOT PALPATE
Abnormal: Enlarged, swollen, tender, hard, immobile
Ex) Supraclavicular node: Enlarged, hard, nontender = metastasis from malignancy in abdomen or
thorax
Hypo- vs. Hyper- Thyroidism
Hyperthyroidism:
Fast; overproduction of thyroid hormone (Graves disease- most common type- Exophthalmos
(bug eyes))
Nervousness, tremor, weight loss w/ increased appetite b/c increased metabolism; poop more
Increase sweating; low heat tolerance,
Enlarged thyroid
Hypothyroidism:
Thyroid hormone deficiency
Not easily palpable- signs come from facial features (puffy face, dry skin); slow pulse/BP
Slow, tired, sleepy, couch potato, constipated
Swelling

Health Assessment
Headaches
Character

Onset/triggers

Location

Duratio
n

Severity

Migrain
e

Nausea/vomiting
Sensitive:
noise/lights

Visual/auditory
Vertigo
Numbness/tingli
ng
Emotions/feeling
s
Food/alcohol

Cluster

Teary/drooping/
red eyes
Runny nose

Sudden
Alcohol

Tension

Anxiety, tension,
depressed

No prodromal
stage
Stress

Tumor

Neurological/men
tal symptoms:
nausea/vomiting

No prodromal
stage
Coughing/sneezi
ng, sudden
movements of
head

Pattern

Assoc.
Factor
s
wome
n

Eyes
Temples
Cheeks
Forehead

Few
days

Severe
throbbin
g
Recurrin
g

Relief:
rest

Eye/orbit
Radiates
to
face/temp
le
Frontal,
temporal,
occipital
lobes

Evenin
gs &
nights

Intense
stabbin
g

Relief:
moveme
nt

Young
males

Days,
months
, years

Dull,
aching,
tight;
diffused

wome
n

Tumor
location

Mornin
g- for
hours

Steady
aching
Intensit
y varies

Relief:
local
heat,
massage
, meds
Relief:
time

---------

Physical exam: normal findings + abnormal findings head and neck

Inspection and Palpation of head
1. Inspect head- size, shape, configuration, involuntary movement
a. Normal: no visible lesions; symmetrically round, erect, midline
i. Can hold head still and upright
b. Abnormal:
i. Features:
Larger skull and bones acromegaly increased production of GH
Acorn-shaped, enlarged skull bones Pagets disease of bone
ii. Movements:
Tremors- neurological disorders- horizontal jerking movement
Involuntary nodding aortic insufficiency
Head tilted unilateral vision, hearing deficiency, sternomastoid
muscle shortening
2. Palpate head
a. Normal: smooth and hard- no lesions
b. Abnormal: lesions, lumps trauma or cancer
3. Inspect face symmetry, features, movement, expression, skin condition
a. Normal: symmetrically round, oval, elongated, square
i. Old people: wrinkles SQ fat decrease w/ age; lower face shrinks, inward
mouth
b. Abnormal:
i. Asymmetry in front of earlobes parotid gland enlargement abscess or
tumor
ii. Unusual/asymmetric face movements- organic disease/ neurological problem
iii. Drooping to one side result of stroke (CVA); Bells palsy
iv. masklike face- Parkinsons disease

Health Assessment
v. sunken face w/ depressed eyes, hollow cheeks- cachexia (wasting away)
vi. Pale, swollen face nephritic syndrome (kidney)
4. Palpate temporal artery
a. Normal: elastic; not tender
b. Abnormal: hard, thick, tender w/ inflammation temporal arteritis lead to
blindness
5. Palpate temporomandibular joint (TMJ)
a. Ask pt to open mouth; explore pts Hx of headaches
b. Normal: no swelling, tenderness, or crepitation (cracking/ sound) w/ movement
i. Full ROM of mouth
c. Abnormal: limited ROM; swelling , tenderness, crepitation TMJ
Inspection of neck
1. Inspect the neck slightly extended neck for symmetry, lumps or masses Side lighting
a. Abnormal:
i. Swelling, enlarged masses/nodules enlarged thyroid gland (huge bulge on
anterior neck)
ii. Inflammation of lymph nodes tumor/ infection
2. Inspect movement of neck structures
a. Pt swallows small sip of water; observe movement of thyroid cartilage/thyroid gland
i. Normal: thyroid cartilage, cricoids cartilage, thyroid gland move up and down
ii. Abnormal: asymmetric movement or generalized enlargement of thyroid
gland
3. Inspect cervical vertebra
a. Pt flex neck- move neck in different directions
i. Normal: C7 visible and palpable; sometimes T1
Older people: cervical curvature- increase b/c of kyphosis (hunchback)
a. Dowagers hump- in older women
ii. Abnormal: prominence or swellings other than the C7 vertebrae
4. Inspect ROM- move head around
a. Normal: movement is smooth and controlled
i. Older people: somewhat decreased ROM- arthritis
b. Abnormal:
i. Stiffness, rigidity, limited mobility Muscle spasm, inflamed, cervical
arthritis

affects daily functioning

Palpate
1. Trachea: fingers on sterna notch; feel each side of the notch
a. Abnormal:
i. Not midline tumor, thyroid gland enlargement, aortic aneurysm,
pneumothorax (air or gas in pleural cavity), atelectasis (collapse of lung),
fibrosis
2. Thyroid gland
a. Hyoid bone- bone that does not articulate with any other bone; high anterior neck
b. Thyroid cartilage adams apple
c. Cricoid cartilage- above sterna notch
i. Abnormal: not midlined; obscured masses; abnormal growth
Palpable thyroid if enlarged hyperthyroidism (Graves disease)
o Edemic goiter, thyroiditis caused by Graves disease
o Rapid enlargement of a single nodule malignancy
Thyroid Auscultation
1. Only if enlarged - Bell on lateral lobes; pt holds breath & blood work
i. Abnormal: soft, blowing, swishing hyperthyroidism- increase blood flow