Comprehensive Comprehensive Health Health

AssessmentAssessmentN275N275

Objective vs. Subjective Objective vs. Subjective DataData

Subjective data is gathered as part of Subjective data is gathered as part of the health history – what the person the health history – what the person says about him/her selfsays about him/her self

Objective data is gathered from the Objective data is gathered from the physicalphysical assessment assessment and laboratory and laboratory studies.studies.

Together they form the data base for Together they form the data base for the client which is the used to make a the client which is the used to make a judgment or diagnosis about the judgment or diagnosis about the health status of the individualhealth status of the individual

Health HistoryHealth History

Biographical dataBiographical data Reason for seeking care (used to be Reason for seeking care (used to be

chief compliant)chief compliant) Present health or history of present Present health or history of present

illnessillness Past historyPast history Family historyFamily history Review of systemsReview of systems Functional assessment or ADL’sFunctional assessment or ADL’s

PQRSTPQRST

Use to explore the reason for seeking Use to explore the reason for seeking care.care.

PP – provocative or palliative – what brings – provocative or palliative – what brings it on? What were you doing when you first it on? What were you doing when you first noticed it? What makes it better? Worse?noticed it? What makes it better? Worse?

QQ – quality or quantity – how does it look, – quality or quantity – how does it look, feel, sound? How intense/severe is it?feel, sound? How intense/severe is it?

RR – region or radiation – where is it? Does – region or radiation – where is it? Does it spread anywhere?it spread anywhere?

S S – severity scale – how bad is it (on a – severity scale – how bad is it (on a scale of 1 to 10)? Is it getting better, scale of 1 to 10)? Is it getting better, worse, staying the same?worse, staying the same?

TT – timing – Onset – exactly when did it – timing – Onset – exactly when did it occur? Duration – how long did it last? occur? Duration – how long did it last? Frequency – how often does it occur?Frequency – how often does it occur?

UU – understand patient’s perception of – understand patient’s perception of the problem. What do you think it the problem. What do you think it means? means?

Assessment TechniquesAssessment Techniques Inspection Inspection – close careful scrutiny. Always – close careful scrutiny. Always

comes first. Requires good lighting, adequate comes first. Requires good lighting, adequate exposure, and occasional instruments exposure, and occasional instruments (penlight, otoscope, ophthalmoscope)(penlight, otoscope, ophthalmoscope)

PalpationPalpation – comes next & confirms points – comes next & confirms points noted during inspection. Use touch to explore noted during inspection. Use touch to explore texture, temperature, moisture, organ texture, temperature, moisture, organ location, swelling, pulsation, rigidity, location, swelling, pulsation, rigidity, crepitation, lumps or masses, and presence crepitation, lumps or masses, and presence of tenderness or pain. Can use the fingertips, of tenderness or pain. Can use the fingertips, grasping of fingers & thumb, dorsa of hands, grasping of fingers & thumb, dorsa of hands, base of fingers or ulnar surface of handbase of fingers or ulnar surface of hand

Percussion –Percussion –tapping the skin with tapping the skin with short sharp strokes to assess short sharp strokes to assess underlying structures. Have a underlying structures. Have a palpable vibration & characteristic palpable vibration & characteristic sound. Percussion sounds are sound. Percussion sounds are resonant over the lungs, tympany resonant over the lungs, tympany over stomach, and dull over organs.over stomach, and dull over organs.

AuscultationAuscultation – listening to sounds – listening to sounds produced by the body through your produced by the body through your stethoscopestethoscope

SkinSkin

Functions Functions Protection from mechanical, chemical, thermal Protection from mechanical, chemical, thermal

damagedamage Barrier to invasion of microorganismsBarrier to invasion of microorganisms Sensory surface – touch, temperature, painSensory surface – touch, temperature, pain Regulates temp through sweatingRegulates temp through sweating Cell replacement for wound repairCell replacement for wound repair Allows for identification through uniqueness of Allows for identification through uniqueness of

facial contours, skin & hair color, & fingerprintsfacial contours, skin & hair color, & fingerprints Tells us about circulation, nutritional status, Tells us about circulation, nutritional status,

systemic disease & the skin itselfsystemic disease & the skin itself

3 layers 3 layers

Epidermis – outer Epidermis – outer layerlayer

Dermis – inner Dermis – inner supportive layersupportive layer

Subcutaneous – Subcutaneous – layer of adipose layer of adipose tissuetissue

EpidermisEpidermis

Thin but tough, cells tightly bound together Thin but tough, cells tightly bound together into sheets that form a protective barrier.into sheets that form a protective barrier.

Stratum germinativum – basal cell layer Stratum germinativum – basal cell layer that produces new skin cells. Melanocytes that produces new skin cells. Melanocytes located throughout this layer – produce located throughout this layer – produce pigment melanin which gives brown tones pigment melanin which gives brown tones to skinto skin

Stratum corneum – layer that consists of Stratum corneum – layer that consists of dead cells that are constantly shed & dead cells that are constantly shed & replaced with new cells from the stratum replaced with new cells from the stratum germinativumgerminativum

Epidermis is completely replaced Epidermis is completely replaced every 4 weeksevery 4 weeks

Uniformly thin, except thicker on Uniformly thin, except thicker on palms & soles due to pressure, palms & soles due to pressure, weight bearing, & friction.weight bearing, & friction.

Avascular layer – nourished from the Avascular layer – nourished from the vessels in the dermisvessels in the dermis

Dermis Dermis

Inner supportive layer made up mainly of Inner supportive layer made up mainly of collagen (connective tissue)collagen (connective tissue)

Collagen is a tough, fibrous protein that Collagen is a tough, fibrous protein that enables skin to resist tearing.enables skin to resist tearing.

Resilient elastic tissue allows the skin to Resilient elastic tissue allows the skin to stretchstretch

Nerves, blood vessels, & lymphatics in this Nerves, blood vessels, & lymphatics in this layerlayer

Hair follicles & sweat glands located in Hair follicles & sweat glands located in dermis & extend up to epidermisdermis & extend up to epidermis

Subcutaneous LayerSubcutaneous Layer

Made up of lobules of fatMade up of lobules of fat Stores fat for energy, insulation for Stores fat for energy, insulation for

temp control, & soft cushioning temp control, & soft cushioning effect for protectioneffect for protection

Epidermal AppendagesEpidermal Appendages

These are located These are located in the dermis, but in the dermis, but proceed up into proceed up into the epidermisthe epidermis

HairHair Sebaceous glandsSebaceous glands Sweat glandsSweat glands Nails Nails

HairHair

Vestigial for humans – no longer needed Vestigial for humans – no longer needed for protection from cold or traumafor protection from cold or trauma

Hairs are threads of keratin. Shaft is the Hairs are threads of keratin. Shaft is the visible portion; root is below the surface visible portion; root is below the surface in the folliclein the follicle

Around the hair follicle are muscular Around the hair follicle are muscular arrector pili, contract & elevate the hair arrector pili, contract & elevate the hair (goose flesh) when exposed to cold or in (goose flesh) when exposed to cold or in emotional statesemotional states

Vellus hair – fine faint hair that covers Vellus hair – fine faint hair that covers most of the body; except palms, soles, most of the body; except palms, soles, dorsa of distal parts of fingers, dorsa of distal parts of fingers, umbilicus, glans penis, & inside labiaumbilicus, glans penis, & inside labia

Terminal hair – darker thicker hair Terminal hair – darker thicker hair that grows on scalp, eyebrows, & that grows on scalp, eyebrows, & after puberty, axilla, pubic area, & the after puberty, axilla, pubic area, & the face & chest of malesface & chest of males

Sebaceous GlandsSebaceous Glands

Produce a protective lipid substance, Produce a protective lipid substance, sebum, which is secreted through hair sebum, which is secreted through hair folliclesfollicles

Sebum oils & lubricates skin & hair Sebum oils & lubricates skin & hair

Most abundant on scalp, forehead, face & Most abundant on scalp, forehead, face & chinchin

Sweat GlandsSweat Glands

Eccrine glands – coiled tubules that Eccrine glands – coiled tubules that open directly onto skin surface & open directly onto skin surface & produce dilute saline solution (sweat)produce dilute saline solution (sweat)

Apocrine glands – produce a thick Apocrine glands – produce a thick milky secretion & open into a hair milky secretion & open into a hair follicle. Located mainly in axillae, follicle. Located mainly in axillae, anogenital area, nipples, & navel. anogenital area, nipples, & navel. When reacting with normal body When reacting with normal body bacteria, produce a musky body odor.bacteria, produce a musky body odor.

NailsNails

Hard plates of Hard plates of keratin on the keratin on the dorsal edges of dorsal edges of fingers & toesfingers & toes

Nail plate is clear, Nail plate is clear, looks pink due to looks pink due to highly vascular highly vascular nailbednailbed

Lunula is a white Lunula is a white opaque semilunar opaque semilunar area at the proximal area at the proximal end of the nailend of the nail

Angle between nail & nail base is 160, Angle between nail & nail base is 160, nail base feels firmnail base feels firm

Provides evidence of systemic diseaseProvides evidence of systemic disease

LesionsLesions

A – asymmetryA – asymmetry B – borderB – border C – colorC – color D – diameterD – diameter E - elevationE - elevation

MaculeMacule

PapulePapule

NoduleNodule

WhealWheal

VesicleVesicle

PustulePustule

CystCyst

CrustCrust

ScaleScale

FissureFissure

Documenting a skin Documenting a skin lesion:lesion:

Type of lesion (macule, papule, vesicle) Type of lesion (macule, papule, vesicle) Anatomic location & distribution Anatomic location & distribution

(generalized or localized)(generalized or localized) Size in millimeters or centimetersSize in millimeters or centimeters Patterns & shape (linear, clustered, ring-Patterns & shape (linear, clustered, ring-

shaped) shaped) ColorColor DrainageDrainage Discrete (individual & distinct) or clustered Discrete (individual & distinct) or clustered

(part of a group)(part of a group)

Assessing the SkinAssessing the Skin

Danger is omission – grow so accustomed Danger is omission – grow so accustomed to seeing the skin, likely to ignore it as to seeing the skin, likely to ignore it as you assess other systems underneathyou assess other systems underneath

Skin assessment is integrated throughout Skin assessment is integrated throughout the complete assessmentthe complete assessment

Techniques used are inspection & Techniques used are inspection & palpationpalpation

Normally assess Normally assess allall the skin – today only the skin – today only assess face, arms, hands, legs & feet.assess face, arms, hands, legs & feet.

Subjective DataSubjective Data Hx skin diseaseHx skin disease Change in pigmentationChange in pigmentation Change in moleChange in mole XS dryness or moistureXS dryness or moisture Pruritus (itching)Pruritus (itching) BruisingBruising Rash or lesion (onset, duration, Rash or lesion (onset, duration,

associated factors, relieving factors, associated factors, relieving factors, treatment & response)treatment & response)

MedsMeds Hair/Nail changesHair/Nail changes

Head & NeckHead & Neck

SkullSkull Rigid bony box that Rigid bony box that

protects the brain & protects the brain & sense organssense organs

Cranial bones – Cranial bones – frontal, parietal, frontal, parietal, occipital, temporal occipital, temporal (use to describe (use to describe findings)findings)

Mastoid process, Mastoid process, orbit, nasal bone, orbit, nasal bone, zygomatic bone, zygomatic bone, mandiblemandible

FaceFace

Facial features are Facial features are symmetricsymmetric

Palpebral fissures Palpebral fissures (opening between (opening between eyelids) equal eyelids) equal bilaterallybilaterally

Nasolabial folds Nasolabial folds (crease from nose to (crease from nose to each corner of each corner of mouth) are mouth) are symmetricsymmetric

2 pairs of salivary 2 pairs of salivary glands accessible to glands accessible to examination – parotid examination – parotid & submadibular& submadibular

Parotid – in the Parotid – in the cheeks over the cheeks over the mandible; largest of mandible; largest of the salivary glands the salivary glands but not normally but not normally palpablepalpable

Submandibular - Submandibular - beneath the mandible beneath the mandible at the angle of the at the angle of the jawjaw

Sublingual – lie in the Sublingual – lie in the floor of the mouthfloor of the mouth

Carotid artery & Carotid artery & jugular veins lie jugular veins lie in the neckin the neck

Temporal artery Temporal artery – superior to – superior to temporalis temporalis muscle, pulsation muscle, pulsation palpable anterior palpable anterior to earto ear

Neck MusclesNeck Muscles Sternomastoid muscle – Sternomastoid muscle –

arises from sternum & arises from sternum & medial part of clavicle & medial part of clavicle & extends diagonally across extends diagonally across the neck to the mastoid the neck to the mastoid process behind the ear process behind the ear (head rotation & flexion)(head rotation & flexion)

Trapezius muscle – form Trapezius muscle – form a trapezoid on upper a trapezoid on upper back. Arises from back. Arises from occipital bone & vertebra occipital bone & vertebra & extends out to scapula & extends out to scapula & clavicle (moves & clavicle (moves shoulders & extends & shoulders & extends & turns head)turns head)

Midline Neck StructuresMidline Neck Structures Hyoid bone – Hyoid bone –

highest up in neck highest up in neck at the floor of the at the floor of the mouthmouth

Thyroid cartilage Thyroid cartilage – above the – above the cricoid cartilage. cricoid cartilage. A palpable notch, A palpable notch, Adam’s apple in Adam’s apple in malesmales

Cricoid cartilage – Cricoid cartilage – above the thyroid above the thyroid about 1 cmabout 1 cm

Thyroid gland – largest Thyroid gland – largest endocrine gland. Has a endocrine gland. Has a rich blood supply & rich blood supply & secretes thyroxine to secretes thyroxine to stimulate the rate of stimulate the rate of cellular metabolism. cellular metabolism. Butterfly shaped with 2 Butterfly shaped with 2 lateral lobes, straddles lateral lobes, straddles the trachea in the the trachea in the middle of the neck. 2 middle of the neck. 2 lobes are connected in lobes are connected in the middle by a thin the middle by a thin isthmus, lying over the isthmus, lying over the 22ndnd & 3 & 3rdrd tracheal rings. tracheal rings. Normal size is 5cm Normal size is 5cm long, 3cm diameter, & 2 long, 3cm diameter, & 2 cm thickcm thick

LymphaticsLymphatics

Rich supply of lymph nodes contained in the Rich supply of lymph nodes contained in the head & neck that are major part of immune head & neck that are major part of immune systemsystem

An extensive vessel system that detects & An extensive vessel system that detects & eliminates foreign substances from the bodyeliminates foreign substances from the body

Vessels allow flow of clear, watery fluid Vessels allow flow of clear, watery fluid (lymph) from the tissue spaces into the (lymph) from the tissue spaces into the circulationcirculation

Lymph nodes are small, oval clusters of Lymph nodes are small, oval clusters of lymphatic tissue set along like beads on a lymphatic tissue set along like beads on a stringstring

Nodes filter Nodes filter the lymph & the lymph & engulf engulf pathogens, pathogens, preventing preventing potentially potentially harmful harmful substances substances from from entering the entering the circulationcirculation

If abnormal, check If abnormal, check the area they drain the area they drain fromfrom

Considered Considered enlarged if greater enlarged if greater than 1 cmthan 1 cm

Could be due to Could be due to infection, allergy, infection, allergy, neoplasmneoplasm

Subjective DataSubjective Data

HeadacheHeadache Head injuryHead injury DizzinessDizziness Neck painNeck pain Lumps or swellingLumps or swelling Hx of head or neck surgeryHx of head or neck surgery