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Thorax, Skin, Hair, Nails

NURB 3060 Spring 2008

Jarvis Chapter 12, 18

Identify subjective data needed to assess respiratory function

Describe techniques utilized to assess the thorax and lungs

Inspection

Palpation

Percussion

Auscultation

Skin, Hair, Nails, Objectives

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

Describe 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

Thorax Objectives

Identify surface landmarks on the thorax

Identify transcultural and developmental considerations in the assessment of the lungs and thorax

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

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 the lungs and thorax

List NANDA diagnoses commonly used in clients with lung disease

Correlate assessment findings with common cardio- pulmonary problems

Quantify edema

Teach skin self-examination

Describe skin changes occurring throughout the lifespan

Describe etiology and detect color changes in light and dark colored skin

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

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 lesions

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.

Percussion

Resonance

Hyperresonance

Increased air

emphysema

Dull

Increased density

Pneumonia

• Resonance • Hyperresonance – Increased air • emphysema • Dull – Increased density • Pneumonia
Adventitious Sounds • Wheeze • Crackles (rhonchi) – Fine (rales) – Hi g h p
Adventitious Sounds
• Wheeze
• Crackles
(rhonchi)
– Fine (rales)
– Hi
g
h
p
itch
– Course
• Sibilant
• Stridor
– Low pitch
• Pleural friction
Sonorous
rub
rhonchi

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

Auscultation

Normal Breath Sounds

bronchial

bronchovesicular

Vesicular

Increased breath sounds

Indicates consolidation

Decreased breath sounds

Obstruction

Hyperinflation

Increased breath sounds – Indicates consolidation • Decreased breath sounds – Obstruction – Hyperinflation

Pulmonary Functions

Pulse oximetry

non-invasive

percent of Hgb saturation

normal 95 -

100%

Pulmonary Functions • Pulse oximetry – non-invasive – percen t of Hgb saturation – normal 95

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.

of the nails. With clubbing, the diamond- shaped window disappears and the angle between the distal

Documentation of Skin

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

Nail Documentation

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

Nails

Nails

Documentation of Hair:

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

Websites of interest Dermatlas.org

Websites of interest • Dermatlas.org Impetigo

Impetigo

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