Vi. examination of the skin and visible mucous membranes. Visible mucous membranes and sclera Inspection of the skin and visible mucous membranes
OBJECTIVE EXAMINATION
GENERAL INSPECTION
Good condition
Satisfactory condition
The condition is serious
ASSESSMENT OF A CHILD'S CONSCIOUSNESS
ASSESSMENT OF THE CHILD'S SITUATION:
SKIN, SUBCUTANEOUS FIBER
AND MUCOUS MEMBRANES
- HUMIDITY
- SKIN ELASTICITY
SUBCUTANEOUS FAT LAYER
On the chest – 1.5-2.0 cm,
Definition SOFT TISSUE TURGORE
MUSCULAR SYSTEM
When assessing the state of the muscular system in children, it is necessary to conduct an EXAMINATION, during which attention should be paid to the degree of muscle development, the presence of atrophy or hypertrophy of individual muscles. To do this, compare the symmetrical muscles of the face, torso, and limbs.
Using the PALPATION method, examination data is clarified and supplemented. Determined MUSCLE TONE, which can be judged by the consistency of muscle tissue determined by palpation. Muscle tone is considered normal if the muscles are sufficiently elastic upon palpation; reduced - muscles seem soft, flabby; elevated – the muscles are hard to the touch. In addition, muscle tone is assessed by the degree of resistance received during passive movements, such as flexion or extension of the upper and lower extremities. If muscle tone decreases, the child’s resistance during passive movements is insufficient, and the range of motion in the joints may be increased. As tone increases, movements are limited or impossible.
In addition to tone, MUSCLE STRENGTH is determined. In young children, muscle strength is judged by the resistance or degree of effort that the child exerts during active movements, for example, when taking away a toy. Muscle strength in older children (preschool and school) can be determined using the following techniques: by the strength of the handshake, if possible, to lift a heavy load, by the ability of resistance that the child provides when bending and straightening the limbs. In school-age children, hand muscle strength is assessed using a hand-held dynamometer.
BONE SYSTEM
When examining the skeletal system, it is necessary to examine all parts of the skeleton (skull of the chest, spine, limbs), and note any existing deformities. Then carry out palpation in the same sequence.
On palpation heads, placing the thumbs of both hands on the forehead, palms on the temporal areas, use the middle and index fingers to examine the parietal bones, occipital region, sutures and fontanelles.
Palpating large fontanel, it is necessary to determine its size - the distance between two opposite sides, pay attention to the condition of its edges, bulging or recessing. On palpation spine determine whether there is any curvature - for this, the child is asked to cross his arms over his chest and at the same time bend forward, and then run his middle and index fingers along the spinous processes from the VI cervical vertebra to the sacrum, identifying deviations from the midline.
JOINTS. It is necessary to examine and palpate them, paying attention to their size, range of motion in a given joint, local temperature, skin color, swelling of soft tissues.
At the end of the skeletal system examination, the circumference of the head and chest is measured using a measuring tape.
RESPIRATORY SYSTEM
When examining the respiratory organs, inspection, percussion, and auscultation are performed.
INSPECTION: During a general examination, pay attention to the position of the patient, the color of the skin and mucous membranes.
When examining the face, check whether breathing through the nose is free or difficult, whether there is nasal discharge, its nature (mucous, serous, purulent, sanguineous, crusts in the nasal passages), complexion, the presence of cyanosis, the degree of its severity (moderate - severe, constant – variable, appears when the child’s position changes, screaming, sucking). It should be remembered that cyanosis in a child appears earlier in the area of the nasolabial triangle - oral. Is there any flaring of the wings of the nose when breathing, shaking of the head in time with breathing, foamy discharge in the corners of the mouth. When examining the chest, pay attention to the presence of shortness of breath, participation of respiratory and auxiliary muscles in the act.
CALCULATE RESPIRATORY RATE. To do this, place your hand on the child's chest or stomach and count the number of respiratory movements in 1 minute. In this case, the child should be in a calm state; it is better for small children to count while sleeping. In newborns and infants, breath counting is best done by holding a phonendoscope to the child’s nose.
BREATHING RATE PER 1 MIN:
Newborns – 40-60,
1st and 2nd year of life – 30-35,
5-6 years – 25-26,
7-10 years – 18-20,
Over 12 years old – 15-16.
CONDUCTING LUNG PERCUSSION:
When percussing the lungs, it is important to give the child the correct position, ensuring symmetry of the chest. It is more convenient for young children to percuss the anterior surface of the chest when the child is lying on his back; back - in a sitting position; Children who cannot yet sit can be placed on their stomach. Older children are best percussed in a sitting or standing position. When percussing the posterior surface, the child is asked to cross his arms over his chest and bend forward slightly; front - the child should lower his arms along the body; lateral - move your arms slightly to the side.
For older children, INTERMEDIATE percussion is used, for younger children - DIRECT.
Indirect percussion: the middle finger of the left hand (“pessimeter”) fits tightly to the chest, percussion blows are made by the middle finger of the right hand, bent at the interphalangeal joints along the middle phalanx of the middle finger of the left hand.
Direct percussion: With the middle finger of the right hand, bent at the waist-phalangeal joints, a light blow is applied to the chest.
When conducting comparative percussion Compare identically located areas of the lungs on the right and left sides:
above and below the collarbones,
along the middle axillary lines, starting from the armpits, moving down one intercostal space,
along the scapular (above, between and below the shoulder blades) and paravertebral lines. The pessimeter finger is positioned along the intercostal spaces in all areas of the ribs, except for the interscapular and axillary regions. In the interscapular region it is located parallel to the spine, and the axillary region is perpendicular, and then parallel to the ribs.
A healthy child has a percussion sound clear pulmonary and in symmetrical areas are the same.
With pathology it is possible:
- SHORTENING, MUTTING percussion sound - when the airiness of the lung tissue decreases, for example, during an inflammatory process.
- GAIN percussion sound, which is called TYMPANIC, up to BOXED– appears when the airiness of the lung tissue (for example, emphysema) increases above the cavities.
AUSCULTATION: carried out with calm and intense breathing, with a cough, it is more convenient for the child to sit in a sitting position, but if the condition is severe, it can also be done while lying down.
Auscultation is carried out in symmetrical areas, the same as during comparative percussion.
First of all, you need to determine your breathing pattern:
Normally audible VESICULAR RESPIRATION, (exhalation is 1/3 of inhalation). In children under three years of age, due to anatomical and physiological characteristics (significant development of interstitial tissue, reducing the airiness of the lung tissue, narrow lumen of the bronchi, thin chest wall), vesicular breathing will be enhanced and is called PUERIL,
In pathological conditions the following can be heard:
A) WEAKENED BREATHING– if less air enters the alveoli (narrowing of the larynx, trachea, bronchi, atelectasis), with pleurisy, inflammatory process (initial and final stages).
b) HARD BREATH(exhalation is more than half of inhalation or equal to it) - it usually indicates damage to the small bronchi, and occurs with bronchitis and bronchopneumonia.
V) BRONCHIAL BREATHING– exhalation is heard better than inhalation, can be reproduced if you blow into the hole of the stethoscope, but normally it is heard above the larynx and trachea; in pathological conditions, you can listen to side effects of sound - WHEELES- They are dry and wet.
DRY– are heard when the bronchi are narrowed or are formed from fluctuations in thick sputum, especially in large bronchi; They are called dry because liquid does not play a big role in their formation.
WHEELING are formed from the passage of air through a liquid, depending on the caliber of the bronchus where they are formed, they are small-medium- and large-bubbly.
Auscultation can also determine crepitus (formed when the terminal sections of the bronchioles separate).
HEATING SYSTEM
INSPECTION: During examination, pay attention to the color of the skin (pallor, jaundice), note the presence of hemorrhage, hemorrhagic rash.
PALPATION: Palpation of the peripheral lymph nodes (see examination of the lymphatic system), liver (see examination of the digestive organs), and spleen is especially important.
When conducting PALPATION OF THE SPLEN the child lies on his back, the examiner’s left hand fixes the left subcostal space, the fingers of the right hand are located at the level of the left costal arch (and if an enlarged spleen is suspected, palpation begins from the iliac crest) and, moving the skin fold downwards, during exhalation, immerse the fingers deep into the abdominal cavity, and with a sigh they move them gradually upward. When palpating the spleen, it is necessary to note how many centimeters it extends from under the edge of the costal arch. An important characteristic of the activity of the hematopoietic organs, the state of the whole organism is PERIPHERAL BLOOD ANALYSIS.
Normal indicators of a child’s hemogram have slightly different values at different age periods. Here are the average hemogram values for a healthy child:
red blood cells 4.0-4.5x10 12 /l
hemoglobin (Hb) 120-140 g/l
leukocytes 8.0-10.0x19 9 /l
platelets 200-300x10 9 /l
ESR 7-8 mm per hour
DIGESTIVE ORGANS
At INSPECTION pay special attention to the stomach - its shape, size, participation in breathing.
The greatest importance when examining the digestive organs is PALPATION. For its correct behavior, the following rules must be observed:
1) the child should lie on his back without a pillow with his legs slightly bent at the hips and knees, arms extended along the body,
2) during palpation of a young child, to reduce tension in the abdominal muscles, it is necessary to distract his attention with toys, older ones with active conversation, offer to breathe deeply with an open mouth,
3) the examiner should sit facing the patient, to his right,
4) palpate with warm hands with short nails.
There are superficial and deep palpation.
SUPERFICIAL PALPATION carried out by slightly pressing the abdominal mesh with the fingers of the right hand. They start from the left groin area, then, palpating the symmetrical areas of the abdomen on the left and right, gradually rise up to the epigastrium, identifying the localization of pain, tension in the abdominal wall, and bloating of intestinal loops. After superficial palpation they begin DEEP, with which you can palpate all parts of the intestines, liver, pancreas, spleen (the latter - see examination of the hematopoietic organs).
PALPATION OF THE LIVER: The left hand fixes the right hypochondrium, and the right hand is placed flat on the area of the right half of the abdominal wall below the level of the navel; during exhalation, the fingers are immersed deep into the abdominal cavity, and while inhaling, they are moved gradually upward. They determine how many centimeters the edge of the liver protrudes from under the costal arch, the nature of the edge (sharp - rounded), and pain. In a burrow, in a healthy child under 5-7 years of age, the liver can be palpated from under the edge of the costal arch by 2-1 cm.
URINARY SYSTEM
DETERMINING THE PRESENCE OF EDEMA: leaks can be identified upon examination - the skin over the swelling appears swollen, there may be traces of clothing on the torso and limbs; on palpation - when pressed, an impression remains, disappearing gradually. Edema is determined in a certain sequence. On the face - during examination, pay attention to swelling or puffiness of the eyelids, puffiness of the face, in the sacral area they press symmetrically on both sides, on the lower extremities it is necessary to press with the index finger in the shin area above the tibia and on the back of the foot.
DEFINITION OF PASTERNATSKY SYMPTOM: When bent fingers tap symmetrical areas of the lumbar region on both sides of the spine in preschool children or with the edge of the palm of the right hand on the back surface of the left hand placed on the lumbar region, pain appears in the kidney area - in this case the symptom is considered positive and indicates kidney damage .
The condition of the urinary system is determined by urine tests.
GENERAL URINE ANALYSIS: consists in determining its physical properties, chemical composition and composition of urine sediment.
GENERAL ANALYSIS OF URINE OF A HEALTHY CHILD:
straw yellow color,
transparency transparent
specific gravity from 1010 to 1025,
no protein or up to 0.033 g/l
Sediment microscopy
leukocytes in boys are single in the field of view;
in girls - up to 5-7 in the field of view;
red blood cells are absent or single in the field of view;
there are no cylinders;
epithelium
flat single cells in the field of view;
renal absent;
CONCLUSION
Having completed the survey, it is necessary to report the data obtained and analyze it. Based on the anamnesis and objective examination, a presumptive diagnosis of the lesion, that is, the leading syndrome, can be made. If the child is healthy, determine the health group. Give recommendations on nutrition and child care.
OBJECTIVE EXAMINATION
After collecting an anamnesis, an objective examination is carried out, which begins with a general examination.
GENERAL INSPECTION
During a general examination, the severity of the condition, consciousness, mood, and position of the child are assessed.
Before starting the examination, it is necessary to reassure the child, gain trust and set him up to work together. It is better to carry out the examination in daylight, placing the child facing the light source in a warm room. Children under 3-4 years of age must be completely undressed before the examination begins; older children must be undressed gradually as the examination proceeds.
The examination begins with an assessment of the general condition.
In acute diseases, it is determined by the severity of toxicosis. There are:
Good condition- only for healthy children.
Satisfactory condition– absence of symptoms of toxicosis – clear consciousness, appetite is preserved or slightly reduced, temperature is subfebrile or normal, facial expression is calm, skin color is pink or moderately pale, respiratory rate, pulse is normal.
Condition of moderate severity - toxicosis is moderately expressed - the condition is preserved, but the child is lethargic, capricious or excited, appetite is reduced or absent, the temperature is often elevated to high numbers, the skin is pale or congested, cyanosis, shortness of breath after physical activity or moderate, expressed at rest, tachycardia.
The condition is serious– marked toxicosis is noted – the child is lethargic, drowsy, apathetic, there may be varying degrees of disturbance of consciousness, convulsions, persistent hyperthermia, expressed by pallor of the skin or diffuse cyanosis, “marbling” of the skin, shortness of breath at rest, sharp tachycardia.
In chronic diseases, the condition is assessed by the degree of damage to a particular system and the degree of decompensation of impaired functions. Most often, a final conclusion about the general condition of the child can be made only after a complete examination.
ASSESSMENT OF A CHILD'S CONSCIOUSNESS
Darkened - the patient’s indifference to his condition, correct but belated answers to questions;
Stupor - numbness: the patient is in deep sleep, when removed from this state, he answers questions sluggishly, the answers are meaningless;
Stupor - stupor: unconsciousness with preserved reaction to painful stimuli;
Coma – deep hibernation: complete absence of consciousness and reflexes; no reaction to external stimuli.
At the same time, the child’s mood is assessed (even, calm, elated, unstable, depressed).
ASSESSMENT OF THE CHILD'S SITUATION:
ACTIVE: the child can take any position in bed and make active movements.
PASSIVE: the child lies motionless and cannot change his position without help.
FORCED: the child takes some special position to alleviate his condition.
After a general inspection, they proceed to a system-by-system examination.
SKIN, SUBCUTANEOUS FIBER
AND MUCOUS MEMBRANES
A skin examination begins with a thorough examination, paying special attention to skin folds.
First of all, the COLOR of the skin and visible mucous membranes is assessed. The skin color of a healthy child is even pale pink. Under the influence of pathological conditions, the color of the skin may change. Pallor of the skin is most often observed; hyperemia (redness), jaundice, and cyanosis (cyanosis) can be detected.
Upon examination, the CLEANITY of the skin is determined - the presence of any rash elements on it (spot, roseola, papule, pustule, etc.), scars, hemorrhages, scratching, manifestations of exudative-catarrhal diathesis, etc. Their prevalence, location, and size are indicated.
SKIN PALPATION: with its help it is determined:
- HUMIDITY– by stroking the skin of the palm or back of your hand on symmetrical areas of the body: chest, back, armpits, groove areas, including palms and soles. Healthy children have moderately moist skin; with pathologies, there may be dryness or increased humidity.
- SKIN ELASTICITY– to determine it, you need to grab the skin (without the subcutaneous fat layer) with the thumbs and index fingers of your right hand and then release. If the fold straightens immediately as soon as the fingers are removed, the elasticity is considered normal; if gradually, it is reduced. Determine the elasticity of the skin on the dorsum of the hand and foot, on the chest or abdomen.
Concept of quantity and distribution SUBCUTANEOUS FAT LAYER can be obtained upon examination by the severity of the bone relief of the shoulder girdle and the smoothness of the contours.
Average (normal) development - the bone relief is slightly smoothed. Insufficient development - the bones of the shoulder girdle are clearly contoured.
Excessive development - the bone relief is smoothed, the contours are rounded. During the examination, attention is also paid to the uniform distribution of the subcutaneous fat layer.
But a final judgment about it is possible only after palpation. To do this, use the thumb and forefinger of the right hand to grab the skin and subcutaneous tissue into the fold and determine the thickness of the resulting fold. Normally it is equal to:
On the stomach, at the level of the navel – 2.0-2.5 cm,
On the chest – 1.5-2.0 cm,
On the back under the shoulder blades – 1.5-2.0 cm,
On the inner side of the thigh – 3.0-4.0 cm,
On the inner surface of the shoulder - at least 1.5 cm.
Definition SOFT TISSUE TURGORE- carried out by squeezing the right river with the thumb and forefinger of the skin and all soft tissues on the inner surface of the thigh and shoulder. This creates a feeling of resistance or elasticity called turgor. If the turgor of soft tissues is reduced, then when compressed, a feeling of lethargy or flabby is determined.
INSPECTION OF VISIBLE MUCOUS MEMBRANES
When examining the lower eyelid, it is necessary to pull it down with your fingers, note the color and the presence of pathological changes (swelling, hyperemia, discharge).
Upon examination ORAL CAVITIES You should pay attention to the condition of the mucous membranes of the lips and oral cavity, teeth, and tonsils.
To thoroughly examine the oral cavity of a young child, it is sometimes necessary to restrain the child. To do this, the assistant or mother takes the child on her lap, sits her back to herself, and squeezes the child’s legs between her legs; The right hand holds the child’s arms and torso, and the left hand holds his head. The examiner should be located to the right of the child and not block the light falling into the oral cavity with his head.
It is necessary to examine the oral cavity using a spatula or spoon, and do not give in to the child’s request to examine the mouth without a spatula. First of all, it is necessary to examine the mucous membrane of the oral cavity, starting with the mucous membrane of the lips, cheeks, gums, then the soft and hard palate, tongue and pharynx. Pay attention to the color of the mucous membrane, its moisture, the presence of hyperemia, aphthae, and thrush. Pay attention to the condition of the tongue (color, moisture, plaque) and teeth (number, permanent or milk teeth, presence of caries). The examination of the oral cavity ends with an examination of the pharynx, paying attention to the condition of the tonsils (hyperemia, plaque).
Examination of the oral cavity and pharynx, as an unpleasant procedure for a young child, should be attributed to the very end of the examination.
When examining the skin and mucous membranes, pay attention to coloring, the presence of rashes, scratching, peeling, and ulcers; for elasticity, firmness (turgor), humidity.
Color (color) of skin and mucous membranes depends on: vascular development; peripheral circulatory conditions; melanin pigment content; thickness and transparency of the skin. Healthy people have flesh-colored, pale pink skin.
Pathological skin coloring:
Pallor: for acute bleeding, acute vascular insufficiency (fainting, collapse, shock); for anemia (anemia), kidney disease, certain heart defects (aortic), cancer, malaria, subcutaneous edema due to compression of the capillaries; for chronic poisoning with mercury and lead. True, pallor of the skin may be in practically healthy individuals: with fear, cooling, an underdeveloped network of skin vessels, low transparency of the upper layers of the skin.
Redness (hyperemia): with anger, excitement, high temperature, fever, alcohol intake, carbon monoxide poisoning; with arterial hypertension (on the face); with erythremia (increased levels of red blood cells and hemoglobin in the blood).
Blue color (cyanosis). Cyanosis can be local and diffuse (general).
Local cyanosis is a consequence of local stagnation of blood in the veins and obstructed outflow (thrombophlebitis, phlebothrombosis).
General Cyanosis most often occurs in diseases of the lungs and heart. According to the mechanism of occurrence, it is divided into central, peripheral and mixed.
· Central occurs in chronic lung diseases (pulmonary emphysema, pulmonary artery sclerosis, pneumosclerosis). It is caused by impaired oxygenation of blood in the alveoli.
· Peripheral cyanosis (acrocyanosis) most often occurs with heart failure, venous congestion in peripheral areas of the body (lips, cheeks, phalanges of fingers and toes, tip of the nose). At the same time, reduced hemoglobin accumulates in the tissues, giving a blue color to the skin and mucous membranes.
· Mixed cyanosis carries features of central and peripheral.
Jaundice. There are true and false jaundice. True jaundice is caused by a violation of bilirubin metabolism. According to the mechanism of occurrence, true jaundices are:
A) suprahepatic (hemolytic)– due to increased breakdown of red blood cells (eg, Rhesus conflict) – lemon-yellow color;
b) hepatic (parenchymal)– due to damage to liver cells due to liver diseases (hepatitis, cirrhosis of the liver) – brick-red;
V) subhepatic (mechanical, obstructive)– due to a violation of the outflow of bile through the bile ducts (glandular disease, cancer of the head of the pancreas, inflammatory processes of the bile ducts) – with a greenish tint.
Jaundice is better detected in daylight. First of all, it appears on the sclera of the eyes and oral mucosa.
False jaundice- the result of taking large doses of certain medications (akrikhin, quinine, etc.), as well as food products (carrots, citrus fruits). In this case, the sclera of the eyes are not stained, bilirubin exchange is within normal limits.
Pale earthy skin tone: with advanced cancer with metastases.
Bronze painting– with adrenal insufficiency (Addison's disease).
Vitiligo – depigmented areas of skin.
Leucoderma - white spots with syphilis.
Café au lait color : for infective endocarditis.
Skin rashes
They are, first of all, a sign of a number of infectious, skin, allergic diseases, but can also be a manifestation of therapeutic diseases.
Blistering rash, or hives– for nettle burns and allergies.
Hemorrhagic rash (purpura)– skin hemorrhages of various sizes (pinpoint petechiae, large bruises) are observed in hemophilia (reduced or absent plasma clotting factors), Wergolf’s disease (thrombocytopenia), capillarotoxicosis (impaired capillary permeability), leukemia (bleeding), allergic conditions, scurvy (vitamin deficiency WITH).
Herpes (blistering rash) for influenza, lobar pneumonia, malaria.
Scars on the skin: after operations, burns, wounds, injuries, syphilitic gummas (star-shaped scars), tuberculosis of the lymph nodes; whitish scars (striae) on the skin of the abdomen after pregnancy or red with Itsenko-Cushing's disease (endocrine disease).
Other skin lesions:“Spider veins” (telangiectasia) with active hepatitis, liver cirrhosis; multiple nodules with tumor metastases; xanthelasmas (yellow spots) on the upper eyelids due to cholesterol metabolism disorders (diabetes mellitus, atherosclerosis); varicose veins, thickening and redness of the skin along the vessels (thrombophlebitis).
Turgor (elasticity, firmness) skin depends on: the degree of development of fatty tissue, moisture content, blood supply, and the presence of elastic fibers. With preserved turgor, a fold of skin taken with the fingers quickly straightens out. Skin turgor decreases in older people (over 60 years old), with severe exhaustion, dehydration (vomiting, diarrhea), and circulatory disorders.
Skin moisture determined by touch:
High humidity occurs physiological (in the heat in summer, with increased muscle work, excitement) and pathological (for severe pain, asthma attacks, fever, severe intoxication, thyrotoxicosis, tuberculosis, lymphogranulomatosis, heart failure).
Dry skin is observed when a large amount of fluid is lost (with uncontrollable vomiting, diarrhea, vomiting during pregnancy, diabetes mellitus and diabetes insipidus, myxedema, scleroderma, chronic nephritis).
When examining the skin and mucous membranes, pay attention to coloring, the presence of rashes, scaling, peeling, and ulcers; for elasticity, firmness (turgor), humidity.
Color (color) of skin and mucous membranes, depends on: vascular development; state of peripheral circulation; melanin pigment content; thickness and transparency of the skin. Healthy people have flesh-colored, pale pink skin.
PATHOLOGICAL SKIN COLOR:
Pallor: for acute bleeding, acute vascular insufficiency (fainting, collapse, shock); for anemia (anemia), kidney disease, certain heart defects (aortic), cancer, malaria, infective endocarditis; with subcutaneous edema due to compression of capillaries; for chronic poisoning with mercury and lead. True, paleness of the skin can also occur in practically healthy individuals: due to fear, cold, an underdeveloped network of skin vessels, and low transparency of the upper layers of the skin.
Redness (hyperemia): with anger, excitement, high temperature, fever, alcohol intake, carbon monoxide poisoning; for hypertension (on the face); with erythremia (increased levels of red blood cells and hemoglobin in the blood).
Blue color(cyanosis). Cyanosis can be diffuse (general) and local. General cyanosis most often occurs in diseases of the lungs and heart failure. Local cyanosis is a consequence of local stagnation of blood in the veins and obstructed outflow (thrombophlebitis, phlebothrombosis). According to the mechanism of occurrence, general cyanosis is divided into central, peripheral and mixed. Central occurs in chronic lung diseases (pulmonary emphysema, pulmonary artery sclerosis, pneumosclerosis). It is caused by impaired oxygenation of blood in the alveoli. Peripheral cyanosis (acrocyanosis) most often occurs with heart failure, venous congestion in peripheral areas of the body (lips, cheeks, phalanges of fingers and toes, tip of the nose). At the same time, reduced hemoglobin accumulates in the tissues, giving a blue color to the skin and mucous membranes. Mixed cyanosis has features of central and peripheral.
Jaundice. There are true and false jaundice. True jaundice is caused by a violation of bilirubin metabolism. According to the mechanism of occurrence, true jaundices are: a). suprahepatic (hemolytic) due to increased breakdown of red blood cells; b). hepatic (for liver damage); V). subhepatic (mechanical) due to blockage of the bile ducts. False jaundice- the result of taking large doses of certain medications (akrikhin, quinine, etc.), as well as foods (carrots, citrus fruits). In this case, the sclera of the eyes are not stained, bilirubin exchange is within normal limits. Jaundice is better detected in daylight. First of all, it appears on the sclera of the eyes and oral mucosa.
Pale earthy skin tone: with advanced cancer with metastases.
Bronze coloration - with adrenal insufficiency (Addison's disease).
Vitiligo– depigmented areas of skin.
Leucoderma- white spots with syphilis.
Café au lait color: for infective endocarditis.
SKIN RASHES. They are, first of all, a sign of a number of infectious, skin, allergic diseases, but can also be a manifestation of therapeutic diseases.
Blistering rash, or urticaria - with nettle burns, allergies.
Hemorrhagic rash (purpura) - skin hemorrhages of various sizes (pinpoint petechiae, large bruises) is observed in hemophilia (reduced or absent plasma clotting factors), Wergolf's disease (thrombocytopenia), capillarotoxicosis (impaired capillary permeability), leukemia (bleeding), allergic conditions , scurvy (vitamin C deficiency).
Herpes (blistering rash) with influenza, lobar pneumonia, malaria.
SCARS ON THE SKIN: after operations, burns, wounds, injuries, syphilitic gummas (star-shaped scars), tuberculosis of the lymph nodes; whitish scars (striae) on the skin of the abdomen after pregnancy or red with Itsenko-Cushing's disease (endocrine disease).
OTHER SKIN DISEASES: “spider veins” (telangiectasia) with active hepatitis, liver cirrhosis; multiple nodules with tumor metastases; xanthelasmas (yellow spots) on the upper eyelids due to cholesterol metabolism disorders (diabetes mellitus, atherosclerosis); varicose veins, thickening and redness of the skin along the vessels (thrombophlebitis).
Algorithm for weighing and determining the patient’s body weight
Purpose: To evaluate physical development or the effectiveness of treatment and nursing care.
Indications: preventive examination, diseases of the cardiovascular, respiratory, digestive, urinary or endocrine systems.
Equipment: medical scales, pen, medical history.
Problems: patient's serious condition.
1st stage. Preparing for the procedure.
1. Collect information about the patient. Politely introduce yourself to him. Ask how to contact him. Explain the procedure and the rules for carrying it out (on an empty stomach, in the same clothes, without shoes; after emptying the bladder and, if possible, bowel movements). Obtain patient consent. Assess the possibility of his participation in the procedure.
Rationale:
establishing contact with the patient;
respect for patient rights.
2. Prepare the scales: align; adjust; close the shutter. Place oilcloth or paper on the scale platform.
Rationale:
ensuring reliable results;
ensuring infectious safety. 2nd stage. Execution of the procedure.
3. Ask the patient to take off his outer clothing, take off his shoes and carefully stand on the center of the scale platform. Open the shutter. Move the weights on the scales to the left until the level of the rocker matches the reference level.
Rationale:
ensuring reliable indicators.
4. Close the shutter. Rationale:
ensuring the safety of the scales.
5. Help the patient get off the weight platform. Rationale:
ensuring a protective regime.
6. Write down the received data (you must remember that a large weight is used to fix tens of kilograms, and a small one - for kilograms and grams).
Rationale:
determining whether the patient’s actual body weight corresponds to the ideal one using the body mass index (BMI) - the Quetelet index.
Note. BMI is equal to a person's actual body weight divided by a person's height squared. With BMI values in the range of 18-19.9, the actual body weight is less than normal; with BMI values in the range of 20-24.9, the actual body weight is equal to the ideal; A BMI of 25-29.9 indicates the pre-obesity stage, and a BMI >30 means that the patient is obese.
7. Provide data to the patient. Rationale:
ensuring patient rights. 3rd stage. End of the procedure.
8. Remove the napkin from the site and throw it into the trash container. Wash the hands.
Rationale:
prevention of nosocomial infections.
9. Enter the obtained indicators into the NIB. Rationale:
ensuring continuity of nursing care.
Note. In the hemodialysis department, patients are weighed in bed using special scales.
When examining, palpating (if necessary) the skin and visible mucous membranes, you should pay attention to the following characteristics.
Coloring of the skin and mucous membranes. Examination reveals pigmentation or its absence, hyperemia or pallor, cyanosis or yellowness of the skin and mucous membranes. Before the examination, you should ask the patient if he has noticed any changes in his skin.
There are several characteristic changes in the color of the skin and mucous membranes.
1. Hyperemia (redness). It can be temporary, caused by taking a hot bath, alcohol, fever, severe anxiety, and permanent, associated with arterial hypertension, working in the wind or in a hot room.
2. Pale. Temporary pallor can be caused by excitement or hypothermia. Severe pallor of the skin is characteristic of blood loss, fainting, and collapse. Hyperemia and pallor are best seen on the nail plates, lips and mucous membranes, especially on the mucous membrane of the oral cavity and conjunctiva.
3. Cyanosis (cyanosis). It can be general and local, central and peripheral. General characteristic of cardiovascular failure. Local, for example, for thrombophlebitis. Central cyanosis is more pronounced on the lips and mucous membrane of the mouth and tongue. However, lips take on a bluish tint even at low ambient temperatures. Peripheral cyanosis of the nails, hands, and feet can also be caused by excitement or low room temperature.
4. Icterus (yellowness) of the sclera indicates possible liver pathology or increased hemolysis. Yellowness may appear on the lips, hard palate, under the tongue and on the skin. Jaundice of the palms, face and soles may be due to the high content of carotene in the patient's food.
Moisture and oiliness of the skin. The skin may be dry, moist or oily. Skin moisture and the condition of subcutaneous tissue are assessed by palpation. Dry skin is characteristic of hypothyroidism.
Skin temperature. By touching the patient's skin with the back of your fingers, you can judge its temperature. In addition to assessing your overall temperature, you should check the temperature of any reddened area of the skin. During the inflammatory process, a local increase in temperature is noted.
Elasticity and turgor (firmness). It is necessary to determine whether the skin folds easily (elasticity) and whether it quickly straightens out after this (turgor). A frequently used method for assessing skin elasticity is palpation.
A decrease in the elasticity and firmness of the skin, its tension is observed with edema and scleroderma. Dry and inelastic skin may indicate tumor processes and dehydration. It must be taken into account that with age, the elasticity of a person’s skin decreases and wrinkles appear.
Pathological elements of the skin. When pathological elements are detected, it is necessary to indicate their characteristics, localization and distribution on the body, the nature of the location, the specific type and time of their occurrence (for example, with a rash). The result of itchy skin can be scratching, which leads to a risk of infection for the patient. When examining, it is necessary to pay special attention to them, since the cause of their occurrence can be not only dry skin, allergic reactions, diabetes mellitus or other pathology, but also scabies mites.
Hairline. During the examination, it is necessary to pay attention to the nature of hair growth and the amount of hair of the patient. People often worry about hair loss or excess hair growth. Their feelings must be taken into account when planning nursing care. A thorough examination can identify individuals with pediculosis (lice infestation).
The discovery of lice and scabies is not a reason to refuse hospitalization. With timely isolation and appropriate sanitary treatment of patients, their stay within the walls of the health care facility is safe for others.
Nails. It is necessary to examine and feel the fingernails and toenails. Thickening, discoloration of the nail plates, and their fragility can be caused by a fungal infection.
The condition of hair and nails, the degree of their grooming, and the use of cosmetics will help to understand the patient’s personal characteristics, his mood, and lifestyle. For example, overgrown nails with half-erased varnish, long-undyed hair may indicate a patient’s loss of interest in his appearance. An unkempt appearance is typical for a patient with depression or dementia, but appearance should be judged based on what is likely to be normal for the individual patient.
Features of the hairline include manifestations hypertrichosis(excessive hair growth on the trunk and limbs), hirsutism(hair growth unusual for age and gender in androgen-dependent areas, including the growth of a beard and mustache). Excessive hair loss resulting in balding patches is called alopecia, which can be local (regional) or total (including absence of eyelashes, eyebrows). There may be early and atypical hair growth in the genital area. Also, when assessing hair, you should pay attention to hardness, thinning, fragility, and unusual hair color. When examining a newborn, one can note the excessive expression of lanugo (fetal fluff), characteristic of prematurely born children.
Examination of mucous membranes
Examination of visible mucous membranes includes examination of the lower eyelid, oral cavity, pharynx, and nose. To examine the conjunctiva, the lower eyelid is pulled down slightly. The degree of blood filling of the mucous membrane (pale, moderate or severe hyperemia) and color change (for example, icterus, cyanotic) are determined. The presence of purulent discharge and the state of secretion of the lacrimal glands are noted. In addition, the condition of the sclera, eyelid skin, eyelashes, and the size and shape of the pupil are assessed.
Examination of the oral cavity and pharynx, as the procedure is unpleasant for the child, should be carried out at the end of the examination. Adequate lighting is important and necessary during inspection. With the child’s mouth slightly open, the condition of the corners of the mouth and the mucous border of the teeth is assessed (presence of “jam”, cheilitis). Then, using a spatula, inspect mucous membranes of the lips, cheeks, palate, gums, sublingual space, condition of teeth. To assess the condition of the child's tongue, the child is asked to open his mouth wide and stick out his tongue as much as possible. Lastly, with the child’s mouth open and the tongue in a calm position (located in the oral cavity), lightly pressing the spatula on the root of the tongue examines the pharynx, the mucous membrane of the posterior wall of the pharynx, and tonsils. When examining the pharynx, the child is not allowed to stick out his tongue or make any sounds (such as “a-a-a”) . Sometimes children, afraid of examining the pharynx, open their mouths and stick out their tongues. An examination in this case can only give an idea of the presence or absence of plaque, but is not sufficient for a detailed assessment. In addition, such a study gives the doctor a false impression of the size of the tonsils - they seem larger than in reality. If necessary, When examining the pharynx, young children have to be fixed. To do this, the mother or assistant sits the child on her knees with her back to herself, the child’s legs are fixed between the assistant’s knees, the right hand holds the torso and arms, the left hand holds the head.
When examining the oral cavity and pharynx, one should take into account color mucous membranes (pink color, pallor, hyperemia, cyanosis, jaundice), their cleanliness(rashes on the mucous membranes, or enanthemas), the presence of thrush, aphthous changes, humidity. Assess the condition of the gums (hyperemia, bleeding), teeth(their number, the presence of caries, changes in bite). Note color, moisture, cleanliness language, the severity of its papillae (sufficient, hypertrophy, atrophy), the possible presence of a “geographical” pattern. When examining the tonsils, an increase in their size, hyperemia, the presence of scar changes, plaque, and caseous plugs are taken into account. About hypertrophy of the palatine tonsils:
Idegrees they say when they occupy 1/3 of the distance from the palatine arch to the midline of the pharynx;
IIdegrees– if they occupy 2/3 of this distance;
IIIdegrees - when they come into contact with each other.
Be sure to describe the condition of the posterior wall of the pharynx (pale or pink, hyperemia, swelling, granularity of the mucous membrane, the presence of mucous or purulent discharge along the posterior wall).
To examine the vestibule of the nose and nasal passages, the researcher, lifting the tip of the nose with the thumb of his right hand, tilts the child’s head back with his left hand and fixes it. The condition of the mucous membrane, the presence of discharge, and freedom of nasal breathing are noted. To assess the latter, the child is asked to breathe deeply through the nose, alternately pinching the nasal passages and pressing on the wings of the nose. Difficulty in nasal breathing, especially in the absence of nasal discharge, may indicate an enlargement of the nasopharyngeal tonsils (adenoids), located behind the choanae and inaccessible to normal examination. Chronic obstruction to nasal breathing leads to the appearance of a nasal voice, decreased hearing, snoring during sleep, malocclusion, dysarthria, and characteristic changes in facial expression. Poor, expressionless facial expressions; small, narrow nose; constantly open mouth with thick lips. All this gives the face a stupid look.
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