NSG 310 HEALTH ASSESSMENT Lecture 3 K. Hendrickson PhD, RN Fall 2013 1.

NSG 310HEALTH ASSESSMENTLecture 3

K. Hendrickson PhD, RN

Fall 2013

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CHAPTER 7Mental 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.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 3

What is Mental Status? Mental status:

Degree of competence/functioning that a person shows in the areas of:

Intellect

Emotion

Psychology

Personality

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Experiences that may affect Mental Health

• Abusive experiences such as:

• Alcohol abuse• Drug abuse• Personal abuse (aka interpersonal violence)

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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.


Anatomy and Physiology: Neurotransmitters


Neurotransmitters & Mental Health • Norepinephrine: excites

or elevates

• Serotonin: stabilizes

• Dopamine: feel good

• Histamine: numbs

• Acetylcholine: tremors

• Gamma-aminobutyric acid (GABA): sedating


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?

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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.

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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):185-98.[2]

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?

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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?

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Anger• Anger:

• 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?

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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• 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

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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?

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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?

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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?

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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

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Problem-Based History:

Alcohol Abuse

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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?

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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

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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• 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• 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

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Question 1After 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:

A. Start taking diphenhydramine at bedtime.B. Be assessed on the Beck short form.C. Undergo AUDIT assessment.D. Undergo CAGE assessment.


CHAPTER 9Skin, 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

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Motion

Tactile Perception

Perfusion

Nutrition Elimination

Tissue Integrity

Oxygenation

Pain

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)

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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

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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.

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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:• Hair, nails, and glands (eccrine sweat glands, apocrine

sweat glands, and sebaceous glands) are considered appendages.


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.

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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.

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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.

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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.

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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.

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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

• 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• 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?

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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• 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

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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• 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

• 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• 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

• 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• 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).

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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• 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• 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• 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

• 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

• 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.

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

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Macule

• Flat, circumscribed area

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

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Papule

• Elevated, Circumscribed area

• Firm• Less than 1 cm diameter

• Examples: warts, elevated moles, lichen planus, cherry angioma, neurofibroma, skin tag

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Vesicles and PustulesVesicle

• Elevated, Circumscribed• Superficial• Filled with serous fluid• Less than 1 cm diameter

Pustule

• Elevated, Circumscribed• Superficial• Filled with purulent fluid• Less than 1 cm diameter

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Scars & KeloidsScar

• Thin to thick fibrous tissue• Replaces normal skin

following injury or laceration to the dermis

• Example: Healed wound after surgical incision

Keloid Scar

• Irregular-shaped, elevated, progressively enlarging scar

• Grows beyond boundaries of wound

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Petechiae & Purpura

Petechiae

• Tiny, flat• Reddish/purple vascular

lesions• Non-blanchable• <0.5 cm in diameter

Pupura• Flat• Reddish/purple vasular

lesion• Non-blanchable

discoloration• > 0.5 cm in diameter

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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.

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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.

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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

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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.

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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.

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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

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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.

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Common Problems and Conditions: Lesions Caused by Abuse

• Bruise (Ecchymosis):• Discoloration from blood seeping into tissues resultingfrom trauma.

• Bite


• Burn

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

• 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?

A. “Do you sleep on your right side?”B. “Does your bra strap rub this mole?”C. “Has this mole changed recently?”D. “Have you applied any creams to this mole?”


Question 2

A pustule is noted over the maxilla of the patient. Which of the following illustrates a pustule?


A.

C.

B.

D.

Question 3An 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?

A. Ecchymosis over coccyxB. Scaling lesion with exudate over

coccyxC. Stage 2 pressure ulcerD. Stage 4 pressure ulcer


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:

1. What risk factors does Silas have for impetigo?

2. What measures might have helped prevent impetigo?

3. What should the nurse do in this clinical situation? Prioritize actions.


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:

1. What risk factors does Sidney have for Tinea capitis?

2. What measures might have helped prevent Tinea capitis?

3. What should the nurse do in this clinical situation? Prioritize actions.


NSG 310 HEALTH ASSESSMENT Lecture 3 K. Hendrickson PhD, RN Fall 2013 1.

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