30 Health Assessment and Physical
Examination 2022
Purposes of the Physical Examination (PE) - conduct PE for many reasons:
Initial evaluation in
... [Show More] triage for emergency
Routine screening to promote wellness behaviors/ preventive health care measures
Eligibility for health insurance
Military service
New job
Admit a patient to hospital
Long term facility
• Gather baseline data about a patient's health status.
• Supplement, confirm, or refute subjective data obtained.
• Identify and confirm nursing diagnoses.
• Make clinical decisions about a patient's changing health
status and management.
• Evaluate the outcomes of care.
Cultural Sensitivity
influences behavior
consider health belief, alternative therapies, nutritional habits, relationships w/ family,
personal comfort zone
Ex. severe asthma episode, the nurse first focuses on the pulmonary and
cardiovascular systems so that treatments can begin immediately. once the pt is no
longer at risk the nurse will perform a comprehensive exam of all body systems
Preparation for Examination: to address cultural diversity - Consider the patients
health beliefs, use of alternative therapies, nutrition habits, relationships with family
and comfort with physical closeness of exam
learn to recognize common characteristics and disorders among ethnic populations
Recognize variations in physical characteristics among ethnic populations skin and
musculoskeletal
Recognize your own knowledge deficits
Consider how the illness may impact the patient, adaptations that may be needed for
the physical assessment, mode of communication, health beliefs and practices,
familial relationships and nutritional practices
Preparation for Examination should include - Head to toe physical assessment is
required daily. always perform a head to toe assessment every time a pt's condition
changes (improves or worsens)
Safety for pts who are confused should be priority never leave a pt who is confused
or combative alone during an examination
Cultural aspects
infection control use standard precautions
Open lesions (wear gloves)
Wound infections
Communicable disease
If there is drainage use additional PPE like isolation gown and eyewear
Ask pt's if they are allergic to latex
3 types of Natural Rubber Latex Allergies
Type 1 response immunological reaction IMgE leads to anaphylactic
Type IV delayed response hypersensitivity: Tcell mediated and appears 48 to 96 hrs
after exposure
Irritant contact dermatitis
environment requires privacy; adequate light; eliminate extra noise and take
precautions to prevent interruptions.
helping pt's on and off to prevent injuries
elevated the head of the table about 30 degrees
Equipment hand hygiene before touching equipment; arrange any necessary
equipment so it is readily available.
Ex. warm the diaphragm of the stethoscope; ophthalmoscope(eye viewing
equipment) and otoscope (ear equipment) have good batteries.
Physical Preparation of the patient with proper dress and draping; Provide the
patient privacy and plenty of time to undress to lessen the patient's anxiety;
Routinely ask whether he or she is comfortable.
Positioning
Patients' abilities to assume positions depend on their physical strength, mobility,
ease of breathing, age, and degree of wellness. only exposed area that needs to be
examine
To decrease the number of position changes, organize the examination so that all
techniques requiring a sitting position are completed first, followed by those that
require a supine position next, and so forth. Use extra care when positioning older
adults with disabilities and limitations
Psychological preparation of the patient explain the purpose and steps of the exam
will let the pt know what to expect
Sitting - areas assessed
Head and neck, back, anterior/Posterior thorax and lungs, breast, axillae, heart, vital
signs, and upper extremities
Rationale
sitting upright provides full expansion of lungs and better visualization of symmetry of
upper body parts
Limitations
physically weakened unable to sit; use supine position with head of the bed elevated
Supine - Area assessed
Head and neck, Anterior thorax and lungs, breast, axillae, heart, abdomen,
extremities, pulse
Rationale
this is normally a relaxed position. provides easy access to pulse sites
Limitations
if pt is Short of breath raise head of bed
Dorsal recumbent - Area assessed
head and neck , anterior thorax and lungs, breasts, axillae, heart abdomen
Rationale
Positions is for abdominal assessment because it promotes relaxation of abdominal
muscles
Limitations
Pts with painful disorders are more comfortable with knees flexed
lithotomy - Area assessed
female genitalia and genital tract
Rationale
position provides maximal exposure of female genitalia and facilities insertion of
vaginal speculum
limitations
Lithotomy position is embarrassing and uncomfortable; thus examiner minimizes
time that patients spends in it. Keep pt well draped
Some patients with arthritis or other joint deformities are unable to assume this
position.
sims' - Area assessed
Rectum and vagina
Rationale
flexion of hip and knee improves exposure of rectal area
Limitation
joint deformities hinder patients ability to bend hip and knee
Prone - Area assessed
musculoskeletal system
Rationale
position is only for assessing extension of hip joint, skin and buttocks
Limitations
Patients with rest difficulties do not tolerate this position well
lateral recumbent - Areas Assessed
heart
Rationale
Position aids in detecting murmurs
limitations
patients with rest difficulties do not tolerate this position well
knee chest - Rectum
Rationale
Position provides maximal exposure of rectal areas
limitations
Embarrassing and uncomfortable
Some patients with arthritis or other joint deformities are unable to assume this
position.
Preparation for Examination: Data collection when examining children - • Gather all
or part of the history on infants and children from parents or guardians. Use openended questions to allow parents to share more information and describe more of
the children's situation. This will allow observation of parent- child interactions. Older
children can be interviewed and provide details about their health history and
severity of symptoms.
• Gain a child's trust before doing any type of an examination. Perform the
examination in a nonthreatening area. Talk and play with the child first. Do the visual
parts of the examination before touching the child. Start the examination from the
periphery and then move to the center (e.g., start with the extremities before moving
to the chest).
• Because parents sometimes think the examiner is testing them, offer support
during the examination and do not pass judgment.
• Call children by their first names and address the parents as "Mr., Mrs., or Ms."
rather than by their first names unless instructed differently.
• Treat adolescents as adults and individuals because they tend to respond best
when treated as such. Remember that adolescents have the right to confidentiality.
After talking with parents about historical information, speak alone with adolescents.
Preparation for Examination: Assessment of age groups; seven variations when
examining older adults - A comprehensive health assessment and examination of
older adults includes physical data; family relationships; religious and occupation
pursuits; and review of the patients cognitive affective and social level
asses ability to perform basic ADL's: bathing and grooming and complex ADL's
making a phone call
remember older pts present subtle or atypical signs and symptoms
• Do not stereotype about aging patients' level of cognition.
• Recognize that some older adults have sensory or physical limitations that affect
how quickly they can be interviewed and examinations can be conducted. It might be
necessary to plan for more than one examination session. Sometimes it helps to give
patients an initial health questionnaire before they come to a clinic or office.
• Perform the examination with adequate space; this is especially important for
patients with mobility aids such as a cane or walker.
• During the examination use patience, allow for pauses, and observe for details.
Recognize normal physiological and behavioral changes that are characteristic of
later life.
• Giving certain types of health information is stressful for older patients. Some view
illness as a threat to independence and a step toward institutionalization.
• Be aware of the location of the closest bathroom in case the patient has an urgent
need to eliminate.
• Be alert to signs of increasing fatigue such as sighing, grimacing, irritability, leaning
against objects for support, and drooping head and shoulders.
Organization of the Examination - Assess each body system during a physical
examination
Patients with focused symptoms or needs require only parts of an examination; thus,
when a patient comes to a clinic with symptoms of a severe chest cold, a
neurological assessment is not usually required.
when admitted to Hospital a complete examination at the time of admission and once
each day to maintain and monitor pt's baseline
for adults examination begins with assessing the head and neck and progress down
the body
keep assessment organized
• Compare both sides of the body for symmetry. A degree of asymmetry is
occasionally normal (e.g., the biceps muscles in the dominant arm are sometimes
more developed than the same muscles in the nondominant arm).
• If the patient is seriously ill, first assess the systems of the body most at risk for
being abnormal. For example, complete a cardiovascular assessment first when
caring for a patient with chest pain.
• If the patient becomes fatigued, offer rest periods between assessments.
• Perform painful procedures near the end of an examination.
• Record assessments in specific terms in the electronic or paper
record. A standard form allows for recording information in
the same sequence that it is gathered.
• Use common and accepted medical terms and abbreviations
to keep notes accurate, brief, and concise.
• Record quick notes during the examination to avoid delays.
Complete any larger documentation notes at the end of the
examination.
Techniques of Physical Assessment - look, listen, and smell to distinguish normal
from abnormal findings
aware of personal visual, hearing, or olfactory deficits.
pay attention to details
Inspection occurs when interacting with a patient, watching for nonverbal
expressions of emotional and mental status and assessing physical movements and
structural components.
• Make sure that adequate lighting is available, either direct or indirect.
• Use a direct lighting source (e.g., a penlight or lamp) to inspect body cavities.
• Inspect each area for size, shape, color, symmetry, position, and abnormality.
• Position and expose body parts as needed so that all surfaces can be viewed but
privacy can be maintained.
• When possible, check for side-to-side symmetry by comparing each area with its
match on the opposite side of the body.
• Validate findings with the patient.
Olfaction helps to detect abnormalities (cranial Nerve I)
Palpation involves using the sense of touch to gather information. make judgments
about expected and unexpected findings of the skin or underlying tissue, muscle,
and bones.
use for skin temp, moisture, texture, turgor, tenderness, and thickness and the
abdomen for tenderness, distention, or masses.
Display respect and concern throughout examination
warm hand; fingernails short and use gentle approach
slowly, gently, and deliberately
promote relaxation by having the pt taking slow deep breaths and place both arms
along the sides of the body
Palpate tender areas last
two types light (pressing inward 1cm superficial) and deep ( depressing the area 4
cm to asses the conditions of organs ) used for Physical examination
Percussion involves tapping the skin with the fingertips to vibrate underlying tissues
and organs. The vibration travels through body tissues, and the character of the
resulting sound reflects the density of the underlying tissue. the denser the quieter
the sound
abnormal sound indicates mass or substance (air or fluid)
note:
location, map their edges and determine size
Auscultation involves listening to internal sounds the body makes to detect variations
from normal.
Bell is best used for low-pitched (vascular and heart sounds) Diaphragm is best for
listening to high pitched sounds (bowel and lungs)
requires concentration and practice.
Describe any sound you hear using the following characteristics:
• Frequency indicates the number of sound wave cycles generated per second by a
vibrating object. The higher the frequency, the higher the pitch of a sound and vice
versa.
• Loudness refers to the amplitude of a sound wave. Auscultated sounds range from
soft to loud.
• Quality refers to sounds of similar frequency and loudness from different sources.
Terms such as blowing or gurgling describe the quality of sound.
• Duration means the length of time that sound vibrations last. The duration of sound
is short, medium, or long. Layers of soft tissue dampen the duration of sounds from
deep internal organs.
Assessment of characteristic odors - alcohol Oral cavity ingestion of alcohol,
diabetes
ammonia Urine urinary tract infection, renal failure
body odor skin, parts that rub together, underarms and under breast poor hygiene,
excess sweat perspiration (hyperhidrosis), foul smelling perspiration (bromhidrosis);
wound site wound abscess; vomitus abdominal irritation, contaminated food
feces vomitus/ oral cavity (fecal odor) bowel obstruction
rectal area fecal incontinence
foul-smelling stools in infants stool malabsorption syndrome
halitosis oral cavity poor dental and oral hygiene, gum disease
sweet, fruity ketones oral cavity diabetic acidosis
stale urine skin uremic acidosis
sweet, heavy, thick odor draining wound pseudomonas (bacterial) infection
musty odor casted body part infection in cast
fetid, sweet odor tracheostomy or mucus secretions infection of bronchial tree
(pseudomonas bacteria )
Skin measure by palpation - temp dorsum of hand/ fingers
moisture palmar surface
texture palmar surface
turgor and elasticity grasping with fingertips
thickness palmar surface
organs (liver or intestine) measured by Palpation - size, shape, tenderness, absence
of masses
Entire palmar surface of hand or palmar surface of fingers
glands (thyroid and lymph) measured by palpation - swelling, symmetry and mobility
pads of fingertips
Blood vessels (carotid and femoral artery) measured by palpation - pulse amplitude,
elasticity, rate, rhythm
palmar surface/ pads of fingertips
Thorax measured by palpation - excursion Palmar surface
tenderness finger pads/ palmar surface of fingers
Fremitus Palmar or ulnar surface of entire hand
Use and Care of the Stethoscope - • Ensure that the earpiece follows the contour of
the ear canals.
• Place the earpieces in your ears with the tips turned toward the face.
• Put on the stethoscope and lightly blow into the diaphragm. If the sound is barely
audible, lightly blow into the bell. Sound is carried through only one part of the chest
piece at a time.
• Place the diaphragm over the anterior part of your chest. Ask a friend to speak in a
normal conversational tone. Environmental noise seriously detracts from hearing the
noise created by body organs. When using a stethoscope, the patient and the
examiner need to remain quiet.
• Put on the stethoscope and gently tap the tubing. It is often difficult to avoid
stretching or moving the stethoscope tubing. The examiner is in a position so that the
tubing hangs free.
• Care of the stethoscope: Remove earpieces regularly and clean; remove cerumen
(earwax). Keep the bell and diaphragm free of dust, lint, and body oils. Keep the
tubing away from any body oils. Avoid draping the stethoscope around the neck next
to the skin. Clean daily or after soiling by wiping the entire stethoscope (e.g.,
diaphragm, tubing) with alcohol. Be sure to dry all parts thoroughly. Follow
manufacturer recommendations.
• Infection control: Harmful bacteria such as gram-positive bacilli, methicillin-resistant
Staphylococcus aureus (MRSA), nonaureus Staphylococcus, Enterobacter cloacae,
and methicillin-sensitive S. aureus can be transferred from patient to patient when
using portable equipment such as stethoscopes. Clean the stethoscope
(diaphragm/bell) before reuse on another patient. Using a disinfectant such as
isopropyl alcohol (with or without chlorhexidine), benzalkonium, or sodium
hypochlorite is effective in reducing the number of bacterial colonies. Hand foam
serves this purpose well. Earpieces of stethoscopes are sources of transferable
bacteria. When you inadvertently touch your ears and care for the patient, potential
pathogens could contaminate the earpieces. Using hand hygiene before and after
patient contact decreases the risk of transmitting microorganisms from your ear to
your patient. Follow the institution's infection control guidelines, especially Contact
Precautions, to decrease this risk
General Survey (appraisal) - When pt walks in observe his or her walk and general
appearance and be attentive to his or her behavior and dress.
presentation and behavior provides info of illness, function idependently, body
image, emotional status, weight change, and developmental status.
General Appearance and Behavior
Assess
Gender and race affects the type of examination (the incidence of skin cancer is
more common in whites than in blacks, prostate cancer is higher in black men than
in white men, and cancer of the bladder is higher in men than in women)
Age influences normal physical characteristics and a person's ability to participate
Signs of distress S&S indicate pain (grimacing, splinting painful area), difficulty
breathing(SOB, sternal retractions) or anxiety. Set priorities and examine the related
physical areas first.
Body type Observe whether the patient appears trim and muscular, obese, or
excessively thin. reflects the health level, age and lifestyle.
Posture Observe whether the patient has a slumped, erect, or bent posture, which
reflects mood or pain. Changes in older adult physiology often result in a stooped,
forward-bent posture, with the hips and knees somewhat flexed and the arms bent at
the elbows
Gait Observe as the patient walks into the room or stands at the bedside (if the
patient is ambulatory) note movements as coordinated or uncoordinated
Body movements Observe whether movements are purposeful, noting any tremors
involving the extremities. Determine whether any body parts are immobile.
Hygiene and grooming level of cleanliness by observing the appearance of the hair,
skin, and fingernails. Determine whether his or her clothes are clean.
Dress Culture, lifestyle, socioeconomic level, and personal preference affect the
selection and wearing of clothing. assess whether the clothing is appropriate for the
temperature, weather conditions, or setting.
Body order unpleasant body odor can result from physical exercise, poor hygiene, or
certain disease states.
Affect and mood Determine whether verbal expressions match nonverbal behavior
and whether the mood is appropriate for the situation. By maintaining eye contact
you can observe facial expressions while asking questions.
Speech is understandable and moderately paced and shows an association with the
person's thoughts. Observe whether the patient speaks in a normal tone with clear
inflection of words.
Signs of patient abuse observe whether the patient fears his or her spouse or
partner, a caregiver, a parent, or an adult child. Observe the behavior of the
individual for any signs of frustration, explanations that do not fit his or her physical
presentation, or signs of injury. Report abuse and make sure patient has safe
housing.
Substance abuse unusual or inconsistent behavior may be indicator of substance
abuse
Vital Signs
Measurement of vital signs is more accurate if completed before beginning positional
changes or movements.
Assess for pain, the fifth vital sign, whenever you take a patient's vital signs.
Temperature Range
Average temperature range: 36° to 38°C (96.8° to 100.4°F)
Average oral/tympanic: 37°C (98.6°F)
Average rectal: 37.5°C (99.5°F)
Axillary: 36.5°C (97.7°F)
Pulse
60 to 100 beats/min, strong and regular
Pulse Oximetry (SpO2)
Normal: SpO2 ≥95%
Respirations
12 to 20 breaths/min, deep and regular
Blood Pressure
Systolic <120 mm Hg
Diastolic <80 mm Hg
Pulse pressure: 30 to 50 mm Hg
Capnography (EtCO2)
Normal: 35-45 mm Hg
Height and Weight
Assess every patient to identify whether he or she is at a healthy weight,
underweight, overweight, or obese
Wt is measured Routinely
Measuring height and weight of older adults, along with obtaining a dietary history
shows risk factors for chronic diseases.
Assessments screen for abnormal weight changes.
weight normally varies daily because of fluid loss or retention.
A weight gain of 2 to 3 lb (0.9-1.4 kg) in 1 day indicates fluid-retention problems. A
weight loss is considered significant if the patient has lost more than 5% of body
weight in a month or 10% in 6 months.
Nursing Hx of Wt assessment - Ask pt of total weight lost or gained and if it was
planned. Always compare current weight with weight history.
Note: gradual, sudden, desired or undesired.
If weight loss desired, ask about eating habits, diet plan followed, food preparation,
calorie intake, appetite, exercise pattern, support group participation, weight goal.
If weight loss undesired, ask about anorexia; vomiting; diarrhea; thirst; frequent
urination; and change in lifestyle, activity, and stress levels.
Assess whether patient has noted changes in social aspects of eating: more meals
in restaurants, rushing to eat meals, stress at work, or skipping meals.
Assess whether patient takes chemotherapy, diuretics, insulin, fluoxetine,
prescription and nonprescription appetite suppressants, laxatives, oral
hypoglycemics, or herbal supplements (weight loss); steroids, oral contraceptives,
antidepressants, insulin (weight gain).
Assess for preoccupation with body weight or body shape such as fasting, never
feeling thin enough, unusually strict caloric intake or restrictions, laxative abuse,
induced vomiting, amenorrhea, excessive exercise, alcohol intake.
General Survey: signs of abuse - Physical injury or neglect are signs of possible
abuse (evidence of malnutrition or presence of bruising) watch for fear of the spouse
or partner, caregiver or parent
Behaviors That Are Suspicious for Substance Abuse
Red flags:
• The risk of suicide, seizures, and violent behavior is high
among substance abusers.
• Intoxicated patients, particularly those with
phencyclidine (PCP) or methamphetamine intoxication, are at significant risk for
becoming agitated and violent, placing themselves and others at risk for injury.
Observe for combinations or repetition of these behaviors:
• Frequently misses appointments
• Frequently requests written excuses for absence from
school or work
• Drops out of school
• Chief complaints of insomnia, "bad nerves," or pain that
do not fit a particular pattern
• Reports lost prescriptions (e.g., tranquilizers or pain
medications) or asks for frequent refills
• Frequent emergency department visits
• History of changing health care providers or brings in
medication bottles prescribed by several different
providers
• History of gastrointestinal bleeds, peptic ulcers,
pancreatitis, cellulitis, or frequent pulmonary infections
• Frequent sexually transmitted infections (STIs),
complicated pregnancies, multiple abortions, or sexual
dysfunction
• Complaints of chest pains or palpitations or has a history
of admissions to rule out heart attacks
• History of activities that place the patient at risk for human immunodeficiency virus
(HIV) infection (multiple partners, multiple rapes)
• Family history of addiction; history of childhood sexual, physical, or emotional
abuse; or social and financial or marital problems
• Intimate partner violence
older adults, risk factors for development of alcohol-related problems include chronic
medical disorders, sleep disorders, social isolation, loneliness, bereavement, and
acute or chronic pain.
When assessing adolescents use Brief Screener for Tobacco, Alcohol, and other
Drugs (BSTAD) and Screening to Brief Intervention (S2BI)
General Survey: CAGE - • Have you ever felt the need to Cut down on your drinking
or drug use?
• Have people Annoyed you by criticizing your drinking or drug use?
• Have you ever felt bad or Guilty about your drinking or drug use?
• Have you ever used or had a drink first thing in the morning as an Eye-opener to
steady your nerves or feel normal?
General Survey: Accurate weight measurement of a hospitalized pt - Wt pts at the
same time of day
On the same scale
In the same clothes
allows an objective comparison of subsequent weights. Accuracy of weight
measurement is important because health care providers base medical and nursing
decisions (e.g., drug dosage, medications) on changes.
standing scale.
Electronic scales
Bed and chair scales
Skin, Hair, and Nails: Assessment of Skin Reveals Health status - Oxygenation
Circulation
Nutrition
Local tissue damage
Hydration
If there is an alteration in integumentary status, then adequate nutrition and
hydration may become priority goals of therapy
risk for skin impairment in a hospital setting. pressure against the skin when the
patient is immobile, reactions to various medications used in treatment, and moisture
if the patient is incontinent or has wound drainage.
high risk are those who have neurological impairments, chronic illnesses, decreased
mental status, poor tissue oxygenation, low cardiac output, or inadequate nutrition or
those who have had orthopedic or vascular injurie
Adequate lighting is required when assessing the skin.
Daylight is the best choice for identifying variations in skin color
fluorescent lighting is the next best choice.
Room temp is important
Warm causes superficial vasodilation resulting in increased redness of the skin.
cool environment causes a sensitive patient to develop cyanosis around the lips and
nail beds
ask nursing history for skin assessment question before inspecting
Inspect all skin surfaces, making a point to do so when examining other body
systems. Often overlooked, inspection of the feet is absolutely essential for patients
with poor circulation or diabetes.
When abnormalities are found you palpate the affected area
Use disposable gloves for palpation if open, moist, or draining lesions are present.
remain alert for skin odors.
Ask patient about history of changes in skin:
Consider whether patient has the following history:
Determine whether patient works or spends excessive time outside.
Determine whether patient has noted lesions, rashes, or bruises.
Question patient about frequency of bathing
skin - Color
Pigmentation Is skin color
Normal skin pigmentation ranges in tone from ivory or light pink to ruddy pink in light
skin and from light to deep brown or olive in dark skin.
older adults, pigmentation increases unevenly, causing discolored skin.
be aware that cosmetics or tanning agents sometimes mask normal skin color.
The assessment of color first involves areas of the skin not exposed to the sun such
as the palms of the hands.
Moisture
The hydration of skin and mucous membranes helps to reveal body fluid imbalances,
changes in the environment of the skin, and regulation of body temperature.
Increased perspiration (sweating) can be associated with activity, exposure to warm
environments, obesity, anxiety, or excitement.
Observe for dullness, dryness, crusting, and flaking that resembles dandruff when
the skin surface is lightly rubbed.
Other factors causing dry skin include lack of humidity, exposure to sun, smoking,
stress, excessive perspiration, and dehydration.
Excessive dryness worsens existing skin conditions such as eczema and dermatitis.
Temperature
depends on the amount of blood circulating through the dermis. Increased or
decreased skin temperature indicates an increase or decrease in blood flow.
An increase in skin temperature often accompanies localized erythema or redness of
the skin. A reduction in skin temperature often accompanies pallor and reflects a
decrease in blood flow.
assess temperature by palpating the skin with the dorsum or back of the hand
Always assess skin temperature for patients at risk of having impaired circulation
such as after a cast application or vascular surgery.
Texture
the appearance of the surface of the skin and how the deeper layers feel. By
palpating lightly with the fingertips, you determine whether the patient's skin is
smooth or rough, thin or thick, tight or supple, and indurated (hardened) or soft.
Older adults will have changes in skin they have decrease in collagen, subcutaneous
fat and sweat glands. Skin becomes wrinkled and leathery
ask the patient about recent injury to the skin when there is irregularities
Deeper palpation sometimes reveals irregularities such as tenderness or localized
areas of induration, caused by an injury or repeated injections.
Condition, Causes and assessment location - Cyanosis increased amount of
deoxygenated hemoglobin / heart or lung disease cold environment assess nail
beds, lips, mouth, skin
Pallor reduced amount of oxyhemoglobin( anemia) assess face, conjunctivae, nail
beds, palms of hands; reduced visibility of oxyhemoglobin resulting from decreased
blood flow(shock) assess skin, nail beds , conjunctivae, lips
Loss of pigmentation vitiligo; congenital or autoimmune condition causing lack of
pigment
Jaundice increased deposit of bilirubin in tissues ; liver disease, destruction of red
blood cells; assess sclera, mucosa membrane, skin
Erythema increase visibility of oxyhemoglobin caused by dilation or increased blood
flow; Fever, direct trauma, blushing, alcohol intake ; face, area of trauma, sacrum,
shoulders, other common sites for pressure injuries
Tan-brown increased amount of melanin; suntan, pregnancy; asses areas exposed
to sun: face, arms, areolas, nipples
Skin, Hair, and Nails: Indicative of substance abuse - Diaphoresis -Sedative
hypnotic (including alcohol)
Spider angiomas- Alcohol, stimulants
Burns (especially fingers)- Alcohol
Needle marks Opioids
Contusion, abrasions, cuts, scars- Alcohol, other sedative hypnotics, intravenous (IV)
opioids
"Homemade" tattoos Cocaine, IV opioids (prevents detection of injection sites)
Vasculitis Cocaine
Red, dry skin Phencyclidine (PCP)
Indurated - hardened
Turgor - refers to the elasticity of the skin.
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