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Thorax, Skin, Hair, Nails

NURB 3060 Spring 2008

Jarvis Chapter 12, 18

Thorax Objectives• Identify surface landmarks on the

thorax• Identify transcultural and

developmental considerations in thedevelopmental considerations in the assessment of the lungs and thorax

• List equipment needed to perform and assessment of the lungs and thorax

• Identify subjective data needed to assess respiratory function

• Describe techniques utilized to assess the thorax and lungslungs–Inspection–Palpation–Percussion–Auscultation

• Differentiate normal and abnormal assessment findings in the normal adult, infant, child, and older adult lung

• Discuss implications of abnormal findings from the assessment of thefindings from the assessment of the lungs and thorax

• List NANDA diagnoses commonly used in clients with lung disease

• Correlate assessment findings with common cardio- pulmonary problems

Skin, Hair, Nails, Objectives

• Obtain subjective data relative to assessment of the skin, hair, nails

• Describe skin lesions using 6Describe skin lesions using 6 characteristics as listed on page 235

• Describe 5 danger signs of pigmented lesions

• Describe skin color variations and their clinical implications

• Quantify edema• Teach skin self-examination• Describe skin changes occurring

throughout the lifespan• Describe etiology and detect color

changes in light and dark coloredchanges in light and dark colored skin

• Describe common skin, hair, and nail lesions and their clinical implications

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• Inspect and palpate the skin, noting color, vascularity, edema, moisture, temperature, texture, thickness, mobility, turgor, and any lesions

• Inspect the fingernails noting color, shape, and any lesionsI t th h i ti t t• Inspect the hair, noting texture, distribution, and any lesions

• Record the history and physical findings accurately, reach an assessment of the health state, and develop a plan of care.

Palpation• Changes in fremitus due to sound is

conducted through dense structures– Decreased

• Obstruction of vibrations–Eg. Pleural effusion

– Increased• Consolidation or compression of lung

tissue–Eg pneumonia

Percussion• Resonance• Hyperresonance

– Increased airIncreased air• emphysema

• Dull– Increased density

• Pneumonia

Auscultation• Normal Breath Sounds

– bronchial– bronchovesicular

Vesicular– Vesicular• Increased breath sounds

– Indicates consolidation• Decreased breath sounds

– Obstruction– Hyperinflation

Adventitious Sounds

• Wheeze (rhonchi)–High pitch

• Crackles – Fine (rales)

CHigh pitch• Sibilant

–Low pitch• Sonorous

rhonchi

– Course• Stridor• Pleural friction

rub

Pulmonary Functions

• Pulse oximetry– non-invasive

t f H b– percent of Hgbsaturation

– normal 95 -100%

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Schamroth technique • Place (dorsal) together

surfaces of the fingertips of corresponding fingers from the right and left hands. Normally, a diamond-shaped window is formed at the base of the nails. With clubbing, the diamond-shaped window disappears and the angle between the distal tips increases.

Nails

Documentation of Skin

• Dark brown, soft, moist, warm; turgor; resilient, returns to place immediately; no edema odor orimmediately; no edema, odor, or excess perspiration; freckling over cheeks and nose; 2 cm scar over right scapula, no keloid; no lesions

Documentation of Hair:

• Coarse, curly, black mixed with gray; male distribution patterns; thinning on crown; nothinning on crown; no infestations

Nail Documentation

• Nail plate smooth, hard, uniform, with longitudinal pigmented bands; nail base angle 160bands; nail base angle 160 degrees, nail bed firm, adhered; nail folds without redness, tenderness, lesions

Websites of interest• Dermatlas.org

Impetigo