Describe primary secondary or vascular lesions

Question

Assignment A: Hair, skin, nails (See below for head, neck and SBAR)

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings
Current Status
1. Skin problems as described by the assessment partner (ask them to describe all rashes, lesions, dry areas, any oiliness, drainage, bruising, swelling, or pigmentation issues)
2. Reported changes in lesion appearance
3. Reported changes in sensation (pain, pressure, itch, tingling)
4. Reported hair loss or changes
5. Reported nail changes
Past History
1. Previous problems with skin, hair, or nails (treatment and surgery)
Family History
1. Family history of skin problems or skin cancer
Lifestyle and Health Practices
1. Exposure to sun or
chemicals
2. Daily care of skin, hair, and nails (use of sunscreen, etc.)

Head and neck Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings
Current Symptoms as reported by assessment partner
1. Reported nodules or lesions on head or neck.
2. Difficulty moving head or neck.
3. Facial or neck pain or frequent headaches.
4. Dizziness, lightheadedness, spinning sensation, or loss of consciousness.
Past History
5. Previous head or neck problems/trauma/injury (surgery, medication, physical or radiation therapy) results.
Family History
6. Family history of head and/or neck cancer.
7. Family history of migraine headaches.
Lifestyle and Health Practices
8. Do you smoke or chew tobacco? Amount? Secondhand smoke?
9. Do you wear a helmet or hard hat?
10. Typical posture when relaxing, during sleep, and when working.
11. Satisfaction with appearance.

Objective data: Hair, skin, nails

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings (In this class when describing objective data, you need to use professional terminology. Most students are weak in this area-review the correct terms in your textbook, such as macule, papule, pustule, etc. No using of "spot", "bump", etc.!
1. Inspect for generalized color variations (pallor, cyanosis, jaundice, erythema, vitiligo).
2. Inspect for skin reactive conditions, such as breakdown or calluses (if applicable, use staging criteria given in Chapter 13).
3. Describe primary, secondary, or vascular lesions. Describe lesions using clinical terminology-macule, papule, pustule, etc.
4. Palpate texture (rough, smooth) of skin, using palmar surface of three middle fingers.
5. Palpate temperature (cool, warm, hot) and moisture (dry, sweaty, oily) of skin, using dorsal side of hand.
6. Palpate thickness of skin with fingerpads.
7. Palpate mobility and turgor by pinching up skin over sternum.
8. Palpate for edema, pressing thumbs over feet or ankles.
Scalp and Hair
9. Inspect color.
10. Inspect amount and distribution.
11. Inspect and palpate for thickness, texture, oiliness, lesions, and parasites.
Nails
12. Inspect for grooming and cleanliness.
13. Inspect for color and markings.
14. Inspect shape.
15. Palpate texture and consistency.
16. Test for capillary refill.

Objective data: Head, neck and lymph nodes

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings
Head and Face
1.Inspect head for size, shape, and configuration.
2.Palpate head for consistency while wearing gloves.
3. Inspect face for symmetry, features, movement, expression, and skin condition.
4. Palpate temporal artery for tenderness and elasticity.
5. Palpate temporomandibular joint for range of motion, swelling, tenderness, or crepitation by placing index finger over the front of each and asking client to open mouth.
Neck
6. Inspect neck while it is in a slightly extended position (and using a light) for position, symmetry, and presence of lumps and masses.
7. Inspect movement of thyroid and cricoid cartilage and thyroid gland by having client swallow a small sip of water.
8. Inspect cervical vertebrae by having client flex neck.
9. Inspect neck range of motion by having client turn chin to right and left shoulder, touch each ear to the shoulder, touch chin to chest, and lift chin to ceiling.
10. Palpate trachea by placing your finger in the sternal notch, feeling to each side, and palpating the tracheal rings.
11. Palpate the thyroid gland.
12. Auscultate thyroid gland for bruits (use both bell and diaphragm of stethoscope).
Lymph nodes: Palpate lymph nodes for size/shape, mobility, and tenderness (refer to display on characteristics of lymph nodes)
13..Preauricular nodes (front of ears)
14. Postauricular nodes (behind the ears)
15. Occipital nodes (posterior base of skull)
16. Tonsillar nodes (angle of the mandible, on the anterior edge of the sternocleidomastoid muscle)
17. Submandibular nodes (medial border of the mandible); do not confuse with the lobulated submandibular gland
18. Submental nodes (a few centimeters behind the tip of the mandible); use one hand
19. Superficial cervical nodes (superficial to the sternomastoid muscle)
20. Posterior cervical nodes (posterior to the sternocleidomastoid and anterior to the trapezius in the posterior triangle)
21. Deep cervical chain nodes (deep within and around the sternomastoid muscle)
22. Supraclavicular nodes (hook fingers over clavicles and feel deeply between the clavicles and the sternomastoid muscles)

SBAR

As you have assessed your patient, which finding would require attention from the Module 2 assessment? (Skin, Hair, Nails, Head, Neck, Eyes, Ears, Mouth, Nose, Throat, or Sinuses). Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing that he/she should utilize sunscreen or ceases using unsafe tanning methods. If your assessment partner has chronic health problems in one of the module areas, you may address one of those problems below.

SBAR
Situation (What is the most important problem you have identified? When did it start, and how severe is it?)
Background (The evidence-Health history relating to this problem, what is being done, and what assessment findings are most important now.)
Assessment (What do you think the problem is-which direction does it seem to be going?)
Recommendation (What needs to happen next?)

Assignment B

Eyes and ears: (See below for mouth, nose, throat, sinuses)

Note that for this assignment (as noted in the syllabus) you need a tuning fork and an otoscope. The instructor priced both of these and found an otoscope at a local drug store for less than $15.00, and a tuning fork from the internet for less than $10.00. These inexpensive models are adequate for this assignment-of course you may be able to borrow them from another nurse for the few moments required to do this assignment, or you may find that you would like to have your own, having learned to use them.

Subjective data Name    

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings
Current Symptoms: Eyes
1. Recent changes in vision?
2. Spots or floaters in front of eyes?
3. Blind spots, halos, or rings around lights?
4. Trouble seeing at night?
5. Double vision?
6. Eye pain?
7. Redness or swelling in eyes with regular daily activity?
8. Excessive watering or tearing or other discharge from eyes?
Past History
9. Previous eye or vision problems (medication, surgery, laser treatment, corrective lenses)?
Family History
10. Family history of eye problems or vision loss?
Lifestyle and Health Practices
11. Exposure to chemicals, fumes, smoke, dust, flying sparks, etc.?
12. Use of safety glasses?
13. Use of sunglasses?
14. Medications (corticosteroids, lovastatin, pyridostigmine, quinidine, risperdal, and rifampin) may have ocular side effects?
15. Has vision loss affected ability to work or care for self or others?
16. Date of last eye examination?
17. Are corrective glasses or contacts worn regularly?
Ears
Current Symptoms
1. Recent changes in hearing (if yes, were all or just some sounds affected)?
2. Ear discharge (if yes, amount/odor)?
3. Ear pain (if yes, is there accompanying sore throat, sinus infection, or problem with teeth or gums)?
4. Ringing or crackling in ears?
Past History
5. Previous ear or hearing problems such as infections, trauma, or earaches (medications, surgery, hearing aids)?
Family History
6. Family history of ear problems or hearing loss?
Lifestyle and Health Practices
7. Live or work around frequent or continuous loud noise?
8. Use of ear protection from noise or while in water?
9. Has hearing loss affected ability to work or care for self or others?

Mouth, nose throat and sinuses: Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings
Current Symptoms
1. Mouth problems (tongue or mouth sores or lesions, gum or mouth redness, swelling, bleeding, or pain)?
2. Sinus problems (pain over sinuses, postnasal drip)?
3. Nose problems (nosebleeds, stuffy nose, cannot breath through one or both nostrils, change in ability to smell or taste)?
Past History
1. Previous problems with mouth, throat, nose, or sinuses (surgeries or treatment; how much and how often)?
2. Use of nasal sprays?
3. History of tooth grinding?
4. Last dental exam? Fit of dentures?
Family History
1. Family history of oral, nasal, or sinus cancer or chronic problems?
Lifestyle and Health Practices
1. Daily practice of oral care, tooth care, or denture care?
2. Usual diet?
3. History of smoking, use of, how much, and how often?
4. Use of alcohol (how much and how often)?

Objective data: Eyes and ears

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings
Current Symptoms: Eyes
Perform Vision Tests	The vision charts for these tests are available at no cost on the internet.
1. Distant visual acuity (with Snellen chart, normal acuity is 20/20 with or without corrective lenses).
2. Near visual acuity (with a handheld vision chart, normal acuity is 14/14 with or without corrective lenses).
3. Visual fields (use procedure discussed in textbook to test peripheral vision).
Perform Extraocular Muscle Function Tests
4. Corneal light reflex (using a penlight to observe parallel alignment of light reflection on corneas).
5. Cover test (using an opaque card to cover an eye to observe for eye movement).
6. Positions test (observing for eye movement).
External Eye Structures
7. Inspect eyelids and lashes (width and position of palpebral fissures, ability to close eyelids, direction of eyelids in comparison with eyeballs, color, swelling, lesions, or discharge).
8. Inspect positioning of eyeballs (alignment in sockets, protruding or sunken).
9. Inspect bulbar conjunctiva and sclera (clarity, color, and texture).
10.Inspect the palpebral conjunctive (eversion of upper eyelid is usually performed only with complaints of eye pain or sensation of something in eye).
11.Inspect the lacrimal apparatus over the lacrimal glands (lateral aspect of upper eyelid) and the puncta (medial aspect of lower eyelid). Observe for swelling, redness, or drainage.
12. Palpate the lacrimal apparatus, noting drainage from the puncta when palpating the nasolacrimal duct.
13. Inspect the cornea and lens by shining a light to determine transparency.
14.Inspect the iris and pupil for shape and color of the iris and size and shape of the pupil.
15.Test pupillary reaction to light (in a darkened room, have client focus on a distant object, shine a light obliquely into the pupil, and observe the pupil's reaction to light-normally, pupils constrict).
16.Test accommodation of pupils by shifting gaze from far to near (normally, pupils constrict).
Internal Eye Structure
17.Inspect the red reflex by using an ophthalmoscope or otoscope to shine the light beam toward the client's pupil (normally, a red reflex is easily seen and should appear round with regular borders). (This is the "red- eye" seen in some home photographs.)
Optional (all blue areas)--may do the following eye assessments if you can, though it is not always possible to do well without dilating the eyes--give it a try and see if you can identify any of the following.	(Your score will not be affected by either your success or inability in this optional section in blue-- it is a skill that takes quite a lot of practice! I recommend that you at least try so that if you take advanced practice classes you will have an idea how it feels.)
2. Inspect the optic disc by using the ophthalmoscope focused on the pupil and moving very close to the eye. Rotate the diopter setting until the retinal structures are in sharp focus (observe disc for shape, color, size, and physiologic cup).
3. Inspect the retinal vessels using the above technique (observe vessels for numbers of sets, color, diameter, arteriovenous ratio, and arteriovenous crossings).
4. Inspect retinal background for color and the presence of lesions.
5. Inspect the fovea and macula for lesions.
Current Symptoms: Ears
External Ear Structures
1. Inspect the auricle, tragus, and lobule for size and shape, position, lesions/discoloration, and discharge.
2. Palpate the auricle and mastoid process for tenderness.
Otoscopic Examination
3. Inspect the external auditory canal with the otoscope for discharge, color and consistency of cerumen, color and consistency of canal walls, and nodules.
4. Inspect the tympanic membrane, using the otoscope, for color and shape, consistency, and landmarks.
5. Have the client perform the Valsalva maneuver, and observe the center of the tympanic membrane for a flutter. (Do not do this procedure on an older client, as it may interfere with equilibrium and cause dizziness.)
Hearing and Equilibrium Tests	An easy-to-perform test for higher-pitched sounds is to rub the tips of your thumb and index finger together, 2 - 3 inches from the patient's ear-D. Furr
6. Perform the whisper test by having the client place a finger on the tragus of one ear. Whisper a two-syllable word (1-2 ft) behind the client. Repeat on the other ear.
7. Perform the Weber test by using a tuning fork placed on the center of the head or forehead and asking whether the client hears the sound better in one ear or the same in both ears.
8. Perform the Rinne test by using a tuning fork and placing the base on the client's mastoid process. When the client no longer hears the sound, note the time interval, and move it in front of the external ear. When the client no longer hears a sound, note the time interval.
9. Perform the Romberg test to evaluate equilibrium. With feet together and arms at the side, close eyes for 20 seconds. Observe for swaying. (Refer to textbook, Chapters 16 and 26.)

Mouth, nose throat and sinuses: Objective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions	Findings
Current Status
Mouth
1. Note any distinctive odors.
2. Inspect and palpate lips, buccal mucosa, gums, and tongue for color variations (pallor, redness, white patches, bluish hue), moisture, tissue consistency, or lesions (induration, roughness, vesicles, crusts, plaques, nodules, ulcers, cracking, patches, bleeding, Koplik spots, cancer sores), Stensen and Wharton ducts.
3. Inspect gums for hyperplasia, blue-black line.
4. Inspect teeth for number and shape, color (white, brown, yellow, chalky white areas), occlusion.
5. Inspect and palpate tongue for color, texture, and consistency (black, hairy, white patches, smooth, reddish, shiny without papillae), moisture, and size (enlarged or very small).
Throat
1. Inspect the throat for color, consistency, torus palatinus, uvula (singular).
2. Inspect the tonsils for color and consistency; grading scale (1, 2, 3, or 4).
Nose
1. Inspect and palpate the external nose for color, shape, consistency, tenderness, and patency of airflow.
2. Inspect the internal nose for color, swelling, exudate, bleeding, ulcers, perforated septum, or polyps.
Sinuses
1. Palpate the sinuses for tenderness.
2. Percuss and transilluminate (if possible) the sinuses for air versus fluid or pus.

Format your assignment according to the following formatting requirements:

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