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Unit-3-B Assessment of the Skin, Head, and
Neck, including Regional Lymphatics Shahzad Bashir
RN, BScN, DCHN, MScN (Std. DUHS) Instructor
New Life College of Nursing Updated October 09, 2015
In The Name of
God
(A PROJECT OF NEW LIFE COLLEGE OF NURSING KARACHI)
Acknowledge; Sir, Hakim Shah
Director, DUHS ION
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Objectives.
By the end of the unit, the learner will be able to:
Review the anatomy & physiology of Integumentary system.
Describe the component of health history that should be elicited during the assessment of skin, head and neck.
Describe specific assessments to be made during the physical examination of the above systems.
Apply braden scale to assess the bed sores of patient
Documents findings.
Describe age related changes in the above systems and differences in assessments findings.
Slide 13-2
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Equipment
Examination light
Penlight
Mirror for client's self-examination of skin
Magnifying glass
Centimeter ruler
Gloves
Wood's light
Examination gown or drape
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Physical Assessment When preparing to examine the skin remember these key points:
Examination of Skin:
Color
Vascularity
Texture: Roughness Eczema, Dermatitis.
Mobility: Decreased in case of edema, Obesity.
Turgor: Decreased due to dehydration.
Moisture:
• Moisture: Dryness (hypothyroidism).
• Sweating (hyperthyroidism).
• Oily(acne).
Skin Lesions
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
1.Brown(deposition of melanin)
Genitical(it is generalized)
Pregnancy(face, nipples ,areola,
Addison disease(exposed areas , pressure
points, genitalia)
Sunlight(exposed areas)
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
2.Blue (cyanosis)
Peripheral: anxiety and cold: observed in extremities and Nail
Central: lung and heart diseases (nails, lips, mucus membrane.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
3.Red colour
Increased visibility of oxyheamoglobin because of dilation of superficial blood vessels e.g. Fever, blushing and local inflammation.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
3.Reddish blue
Combination of increased in level of hemoglobin & reduced in hemoglobin & capillary stasis e.g. Polycythemia, observed on hands, feet, conjunctiva, mouth face etc
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
4.Yellow
Jundice:increased level of bilirubin; first in sclera then mucus membrane & skin
Carotenemia:increased level of carotenoids due to maxidema, hypopitutrism and diabetes observed on palm,sole and face does not involve sclera and mucus membrane
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Decreased Colour
Congenital (Albinism):Inability to form melanin it is generalized.
Acquired (vitiligo):patchy symmetrical often involved exposed area.
Anemia: decreased level of hemoglobin evident in conjunctiva.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
An evidence of bleeding and bruising
• Petechia: pin point hemorrhage beneath the skin usually 1-3mm round and flat this suggest increased bleeding tendency.
• Echymosis: purple, purplish blue and some time brown, larger then Petechia secondary to trauma and bleeding disorder.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Skin. Lesions:
Location/ Distribution.
Configuration.
Morphology:
Primary
Secondary
Vascular
Pururic
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Head.
SCALP:
Scaliness
Lumps
Lesions.
SKULL:
Size
Contours
Deformities
Lumps
Tenderness
Unusual Movement.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of mouth include Examination of:
Lips
Gums
Teeth
Tongue
Palate
Orophayrnx
Mucus membrane
Breath/smell
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of lips
Colour: Blue in Cyanosis pale in anemia, normal lips are smooth and pink.
Any congenital abnormality i.e. Cleft lip
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Ulcers
Snail track ulcers are is observed in syphilis.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Vesicles
In herpes simplex infection produced grouped vesicles on lips with red base.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Fissures
Mostly seen in hot season, dehydration, and pathological in anemia
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Gums
Blue line running along the edges of gum in lead poisoning.
Gums are swollen and spongy in case of scurvy.
In gingivitis the edges of gums are red and bleed easily
Pyorrhea: pus between teeth and gums
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
gingivitis
Scurvy
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Tongue
Colour: Blue in Cyanosis pale in anemia
Red beefy tongue in deficiency of riboflavin
Black tongue in patient taking
iron mixture. also in Addison
diseases.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Symmetry of tongue
Slightly deviated normally from its mid line
Grossly deviated towards its side due to 12th cranial nerve paralysis.
Tremor: tremors of tongue in Parkinson diseases. And in severe thyrotoxicosis.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Surface of tongue
Dry tongue in case of anxiety and dehydration.
Bald tongue in anemia (iron deficiency & pernicious).
Furring of tongue in excessive
smoking.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Red strawberry tongue
In scarlet fever .
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Ulcers Malignant ulcers
T.B ulcers on tip of tongue
Patches on tongue in thrush and leuokoplekia.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of under surface
Ask the patient to touch the hard palate with the tip of the tongue
In tongue tie he is unable to touch the palate
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Size of Tongue
Enlarged tongue in hypersecretion of growth hormone.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Palate
Examine the palate , orophayrenx, & mucus membrane for colour pigments and deformity etc.
A dirty gray colored membrane (pseudo membrane)is observed in diphtheria.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Breaths/smell
Fishy: Uremia
Mousy: Liver cirrhosis
Fruity: Diabetes
Foul: In case of dirty teeth , mouth ulcers etc.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Head.
Quality(Texture)
Quantity
Cleanliness
Distribution
Pattern of loss
Infestation
HAIR:
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Nails.
Color
Contour
Curvature/Angle
Symmetry
Cleanliness
Adherence to nail bed
Thickness
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Normal: the angle between finger nail and nail bad is 160 degree.
Abnormal Nails
Bluish colour: in Cyanosis
Decreased capillary refill in anemia.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Koilonychias
Spoon Shaped Nails in Iron Deficiency Anemia
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Clubbing
The Angle between Nail and base of nail is 180 degree or more e.g. cynosis
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Splinter hemmoharrage
Red or brown linear lines on nails due to trauma.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Paronychia
Inflammation of Skin around nails.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Fungal Nails
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Face.
Proportion/ Contour.
Expression.
Movement.
Sensation.
Lymph Nodes.
Edema/Lesions/Masses.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Neck.
Symmetry.
Trachea.
Lymph Nodes.
Thyroid gland.
Movement
Masses, Swelling, Skin discoloration.
Arterial pulsation & Venous distension.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Examination of Thyroid.
Examination of lymph node.
Describe enlarge node under the following terms.
Location
Size
Shape
Surface characteristics
Consistency
Mobility/ Fixation
Sign of Inflammation
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Structure and Function
Subjective Data—Health History Questions
Objective Data—Physical Exam
Abnormal Findings
Slide 13-41
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Structure and Function
Head
Cranial bones
Sutures
Facial bones
Facial muscles
Salivary glands
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Structure and Function (cont.)
Neck
Neck muscles
Anterior and posterior triangles
Thyroid gland
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Structure and Function (cont.)
Lymphatics
Preauricular
Posterior auricular (mastoid)
Occipital
Submental
Submandibular
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Structure and Function (cont.)
Lymphatics (cont.)
Jugulodigastric
Superficial cervical
Deep cervical
Posterior cervical
Supraclavicular
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Structure and Function (cont.)
Developmental care
Infants and children
Fontanels
Head growth
Lymphatic system
Pregnant female
Aging adult
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Subjective Data— Health History Questions
Headache
Head injury
Dizziness
Neck pain or limitation of motion
Lumps or swelling
History of head or neck surgery
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Subjective Data— Health History Questions
(cont.)
Additional history for infants and children
Maternal alcohol or drug use
Type of delivery
Growth pattern
Additional history for aging adult
Dizziness
Neck pain
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Objective Data— Physical Exam
Head–Inspect and palpate the skull
Size and shape
Temporal area
Head–Inspect the face
Facial structures
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Objective Data—Physical Exam (cont.)
Neck–Inspect and palpate
Symmetry
Range of motion
Lymph nodes
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Objective Data—Physical Exam (cont.)
Neck–Inspect and palpate (cont.)
Trachea
Thyroid gland
Posterior approach
Anterior approach
Auscultate
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Objective Data—Physical Exam (cont.)
Developmental care
Infants and children
Skull
Face
Neck
Special procedures
Pregnant female
Aging adult
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Sample Charting
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Sample Charting (cont.)
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Sample Charting (cont.)
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PRIMARY& SECONDARY SKIN LESIONS
•Lesions should be observed for
• Anatomical location
• Arrangement and grouping
• Type of skin lesion
• Color of lesion
• Primary skin lesions are original lesions arising from previously normal skin.
• Secondary lesions can originate from primary lesions.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Conti…
Primary Skin Lesions
Non palpable Change in Skin
Color.
Macule, Patch
Palpable elevated solid masse.
Papule, Plaque, Nodule, Tumors,
Wheal, Cyst,
Palpable elevated serous fluid filled
cavities.
Vesicles, Bulla, Pustules,
Secondary Skin Lesion
Erosions. Ulcers, Fissure, Scales,
Crust, Scar, Lichenification, Atrophic Skin,
Keloids,
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Primary Skin Lesions
There are three types of primary lesions
Non palpable Change in Skin Color.
Palpable elevated solid masse.
Palpable elevated serous fluid filled cavities.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
1.Non palpable Change in skin colour
Macule:<1cm circumscribed boarder e.g. Mole,patachia.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Patch:>1cm may have irregular boarder
e.g. Vitiligo, Freckles, Echymosis
Macule and patches are non palpable skin
changes. colour may be brown, white, Purple red
etc. Slide 13-60
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
2. Palpable Elevated Solid Masses
Papule: <0.5 cm Elevated Navi,Warts
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Plaque: >0.5 cm with circumscribed
boarder e.g. Psoriasis, actinic karatosis
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Nodule:0.5-2cm with circumscribed
boarders e.g Lipomas, Squamous cell
Carcinoma.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Tumors: .1-2 cm (>2cm extends deeper
into the tissue)
e.g. Large lipomas Carcinomas.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Wheal: Elevated mass with transient
boarders caused by movement of serous
Fluid in dermis does not contain free fluids
in cavities like vesicles e.g. insect bite,
Uriticaria.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Cyst: Encapsulated fluid filled or semi solid
masses in the subcutaneous
Tissue or dermis e.g. Sebaceous cyst
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
C. Palpable elevated fluid filled cavities
Vesicles: <0.5 cm with circumscribed boarder e.g. Chicken pox, 2nd degree burn blister.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Bulla: >0.5cm Circumscribed boarder e.g
Large burn blister, contact dermatitis,
Bullous impetigo
Pustules: pus filled vesicles or bulla e.g Impetigo, furuncle
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Secondary Lesions
Erosions: loss of superficial epidermis, does not extend to dermis , with moist area e.g. Scratch marks, ruptured vesicles.
Slide 13-69
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Ulcers: Skin extends to dermis e.g. Pressure ulcers
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Fissure: linear cracks in skin e.g. athletes foot
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Scales: Flakes secondary to dead epithelium
e.g. psoriasis, dry skin, pityriasis rosea.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Crust: Dried residue of serum blood or
pus e.g residual left following
Vesicles, impetigo, eczema
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Scar: Skin mark after wound Healing
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Lichenification: Thickening & Roughening of
the skin .Contact Dermatitis, Eczema.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Atrophic Skin: Thin , dry, transparent
appearance of Epidermis e.g. Aged Skin
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
Keloids: Hypertrophic scar tissue
secondary to excessive collagen
formation during healing.
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
References.
Bicklay, L. S. (1999). Bates’ guide to physical examination and history taking (7th ed). Philadelphia: J.B. Lippincott.
Weber, J. & Kelley, J.(2007). Health assessment in nursing (3rd ed). Williams & Wilkins: Lippincott.
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