HEALTH ASSESSMENT EXAM 1
Age Related variations in SHN assessments - ANS-Infants and Children
-The assessment of skin among infants and children follows the same general principles as
previously described for the adult. Skin lesions common to infants and children include milia,
erythema toxicum, diaper rash, and rashes associated with allergens. Chapter 19 presents
further information regarding the assessment of skin, hair, and nails for these age-groups.
Adolescents
-The most common skin lesions of concern among adolescents are acne because of the
increase in sebaceous gland activity. Not only are these lesions painful, but also they are of
concern to the patient because of personal appearance. Chapter 19 presents further
information.
Older Adults
-The skin and hair undergo significant changes with aging. Many lesions found on older adults
are considered expected variations associated with the aging process. Inspection of
sun-exposed areas is important because the incidence of skin cancer increases with age.
Further information related to changes of the skin and lesions commonly found among older
adults is presented in Chapter 21.
Cultural Variations
- Cultural variation in treatments and remedies one may use
- Nurse must demonstrate sensitivity to dealing with the way one wishes to practice hygiene and
self-care
- Nurse must also be sensitive to the level of modesty the patient wishes to attain and/or their
preference to gender of nurse conducting the assessment
Situational Variations
-Patients with Limited Mobility
- Patients with limited mobility are at risk for skin breakdown secondary to pressure and body
fluid pooling
- an inability to feel pressure or a decreased ability to independently change position to relieve
pressure is a risk factor for pressure injuries
- The nurse should examine the patient's skin, especially over bony prominences
- patients who operate their own
,\Alopecia areata - ANS-Chronic inflammatory disease of hair follicles resulting in hair loss on
scalp.
\Atopic - ANS-Superficial inflammation
\Auscultation - ANS-involves listening to sounds within the bod. A stethoscope is used usually to
auscultate. Better to do it in a quiet room, no clothing, warm the stethoscope if necessary
\Biographic data - ANS-name, gender, address, phone #, email, DOB, Birthplace, race/ethnicity,
religion, marital status, occupation, contact person, source of data
\Civility behaviors - ANS-polite, reasonable, respectful behavior, polite actions and words,
Courtesy 2-way street: 1) Instructor's responsibility - establish safe, engaged learning
environment 2) Student's responsibility - refrain from disruptive classroom behavior that shows
disrespect/disregard for instructor and fellow students (late arrivals, texting, foul language, cell
-phone use)
\Contact: Inflammatory reaction to irritant or allergen - ANS-Localized erythema.
May weep, ooze, or crust.
\Define and explain the use of Standard Precautions. - ANS-Precautions developed by the CDC
that ensures that universal precautions and body substance isolation practices are being
followed.
Proper hand washing technique must be done.
\Define the term assessment in the context of the nursing process. - ANS-Assessment is a
systematic method of collecting and analyzing comprehensive data for the purpose of planning
centered patient care
\Demonstrate history-taking and examination techniques appropriate for the SHN - ANS-Collect
subjective data about their present health and any past experiences. In addition to present
health status, past health history, family history, and personal and psychosocial history, ask
patients about their home environment, occupational environment, and travel, which may affect
the health condition of their skin, hair, and nails
\Dermatitis - ANS-Variety of superficial inflammatory conditions
\Dermis - ANS-- made up of highly vascular connective tissue
- The blood vessels dilate and constrict in response to external heat and cold and internal
stimuli such as anxiety or hemorrhage, resulting in the regulation of body temperature and blood
pressure
- also contains sensory nerve fibers that react to touch, pain, and temperature
- The arrangement of connective tissue enables the dermis to stretch and contract with body
movement
- Dermal thickness varies from 1 to 4 mm in different parts of the body
\Describe abnormal findings that may be identified by examination of the SHN. - ANS-SKIN
Skin Color:
Cyanosis
Pallor
Jaundice
Localized Variations in color:
Melanoma
, Vitiligo
Texture:
Excessive dryness, flaking, cracking, scaling
May be secondary to environmental conditions or signs of systemic disease, or nutritional
deficiency
Temperature:
Cool skin: maybe shock or hypothermia
Cool skin: in extremities might be an indication of poor peripheral perfusion
Hot skin: hyperthermia if the generalized skin is hot; associated with fever, increased metabolic
rate (hyperthyroidism), or exercise
Hot skin: if localized, may reflect inflammation, infection, trauma, thermal injury (sunburn)
Moisture:
Diaphoresis (excessive sweating); might be caused by hyperthermia, extreme anxiety, pain, or
shock
Excessively moist skin often seen in conditions of hyperthyroidism
Mobility and Turgor
Skin mobility: affected by edema, excessive scarring, or connective tissue disorders like
scleroderma
Poor Turgor: " tenting" observed, or skin is slow to move back into place
Poor Turgor: results from dehydration or person who lost significant amount of weight
Thickness:
Thick skin: seen with diabetic patients
Thin skin: can be shiny or transparent; seen in hyperthyroidism, arterial insufficiency, and aging
HAIR
Texture:
Age Related variations in SHN assessments - ANS-Infants and Children
-The assessment of skin among infants and children follows the same general principles as
previously described for the adult. Skin lesions common to infants and children include milia,
erythema toxicum, diaper rash, and rashes associated with allergens. Chapter 19 presents
further information regarding the assessment of skin, hair, and nails for these age-groups.
Adolescents
-The most common skin lesions of concern among adolescents are acne because of the
increase in sebaceous gland activity. Not only are these lesions painful, but also they are of
concern to the patient because of personal appearance. Chapter 19 presents further
information.
Older Adults
-The skin and hair undergo significant changes with aging. Many lesions found on older adults
are considered expected variations associated with the aging process. Inspection of
sun-exposed areas is important because the incidence of skin cancer increases with age.
Further information related to changes of the skin and lesions commonly found among older
adults is presented in Chapter 21.
Cultural Variations
- Cultural variation in treatments and remedies one may use
- Nurse must demonstrate sensitivity to dealing with the way one wishes to practice hygiene and
self-care
- Nurse must also be sensitive to the level of modesty the patient wishes to attain and/or their
preference to gender of nurse conducting the assessment
Situational Variations
-Patients with Limited Mobility
- Patients with limited mobility are at risk for skin breakdown secondary to pressure and body
fluid pooling
- an inability to feel pressure or a decreased ability to independently change position to relieve
pressure is a risk factor for pressure injuries
- The nurse should examine the patient's skin, especially over bony prominences
- patients who operate their own
,\Alopecia areata - ANS-Chronic inflammatory disease of hair follicles resulting in hair loss on
scalp.
\Atopic - ANS-Superficial inflammation
\Auscultation - ANS-involves listening to sounds within the bod. A stethoscope is used usually to
auscultate. Better to do it in a quiet room, no clothing, warm the stethoscope if necessary
\Biographic data - ANS-name, gender, address, phone #, email, DOB, Birthplace, race/ethnicity,
religion, marital status, occupation, contact person, source of data
\Civility behaviors - ANS-polite, reasonable, respectful behavior, polite actions and words,
Courtesy 2-way street: 1) Instructor's responsibility - establish safe, engaged learning
environment 2) Student's responsibility - refrain from disruptive classroom behavior that shows
disrespect/disregard for instructor and fellow students (late arrivals, texting, foul language, cell
-phone use)
\Contact: Inflammatory reaction to irritant or allergen - ANS-Localized erythema.
May weep, ooze, or crust.
\Define and explain the use of Standard Precautions. - ANS-Precautions developed by the CDC
that ensures that universal precautions and body substance isolation practices are being
followed.
Proper hand washing technique must be done.
\Define the term assessment in the context of the nursing process. - ANS-Assessment is a
systematic method of collecting and analyzing comprehensive data for the purpose of planning
centered patient care
\Demonstrate history-taking and examination techniques appropriate for the SHN - ANS-Collect
subjective data about their present health and any past experiences. In addition to present
health status, past health history, family history, and personal and psychosocial history, ask
patients about their home environment, occupational environment, and travel, which may affect
the health condition of their skin, hair, and nails
\Dermatitis - ANS-Variety of superficial inflammatory conditions
\Dermis - ANS-- made up of highly vascular connective tissue
- The blood vessels dilate and constrict in response to external heat and cold and internal
stimuli such as anxiety or hemorrhage, resulting in the regulation of body temperature and blood
pressure
- also contains sensory nerve fibers that react to touch, pain, and temperature
- The arrangement of connective tissue enables the dermis to stretch and contract with body
movement
- Dermal thickness varies from 1 to 4 mm in different parts of the body
\Describe abnormal findings that may be identified by examination of the SHN. - ANS-SKIN
Skin Color:
Cyanosis
Pallor
Jaundice
Localized Variations in color:
Melanoma
, Vitiligo
Texture:
Excessive dryness, flaking, cracking, scaling
May be secondary to environmental conditions or signs of systemic disease, or nutritional
deficiency
Temperature:
Cool skin: maybe shock or hypothermia
Cool skin: in extremities might be an indication of poor peripheral perfusion
Hot skin: hyperthermia if the generalized skin is hot; associated with fever, increased metabolic
rate (hyperthyroidism), or exercise
Hot skin: if localized, may reflect inflammation, infection, trauma, thermal injury (sunburn)
Moisture:
Diaphoresis (excessive sweating); might be caused by hyperthermia, extreme anxiety, pain, or
shock
Excessively moist skin often seen in conditions of hyperthyroidism
Mobility and Turgor
Skin mobility: affected by edema, excessive scarring, or connective tissue disorders like
scleroderma
Poor Turgor: " tenting" observed, or skin is slow to move back into place
Poor Turgor: results from dehydration or person who lost significant amount of weight
Thickness:
Thick skin: seen with diabetic patients
Thin skin: can be shiny or transparent; seen in hyperthyroidism, arterial insufficiency, and aging
HAIR
Texture:
