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NUR 220 ~ HEALTH ASSESSMENT IN NURSING
I. Evidence-based Health Assessment a. Priority Levels i. First level
1. Life threatening problems – LIFE THREATENING a. AIR WAY PROBLEMS b. BREATHING PROBLEMS i. Rate, depth, pattern and breathing sounds c. CIRCULATION PROBLEMS i. Heart rate, BP, tissue perfusion, beating of the heart (what is their EKG?) ii. Second Level 1. Avoid deterioration 2. Change in mental status 3. Acute pain a. Short term – 3to 6 months b. Soft tissue i.e. sprains, paper cut i. Gradually resolves 4. Acute Urinary elimination problems 5. Abnormal labs – life threatening 6. Risks of infection 7. Safety or security problems 8. DM w/ no insulin iii. Third Level 1. These interventions take more time and are planned out over a long period of time 2. UTI – depending on what other issues are presented… iv. Collaborative Problems 1. Physiological complication that nurses monitor for to detect the onset of changes in a patient’s status. Nurses intervene in collaboration with other personnel from other disciplines a. Physical therapy, surgical wound b. Types of Assessment : i. Complete 1. Full physical – includes current and past health history a. Review systems ii. Focused/problem-centered/episodic 1. Problem-centered/episodic/focused a. Whatever system is affecting them b. Addresses specific problem i. After asthma attack, cough, surgery iii. Follow-up 1. Assessment after treatment 2. Determine status to see if treatment is working 3. Inform of side effects from treatment 4. Relapse iv. Emergency
1. Rapid collection of data a. Happens while life saving measures are being performed II. General Survey a. Components of the General Survey i. First impression of a patient 1. Physical appearance a. LOC: Alert, oriented, verbally responds, Motor response, Age, gender, expression, facial features, signs of stress 2. Body structure : gait, posture, ROM, nutrition status, deformities (Accident or hereditary), assistive devices 3. Behavior : Mood/affect , Eye contact , Speech, Dress , Grooming **III. The Interview a. Interview Phases i. Working phase
- Data gathering phase a.** Obtain subjective (what the pt says) & objective data (what you obtain from tests or observations) b. Your verbal skills include ability to form questions appropriately and receive appropriate from patient. **ii. Types of Interview Questions
- Open ended questions a.** Why are you here? You said…tell me more? Anything else? b. Responses are in paragraphs 2. Closed/direct questions a. 1 - or 2-word responses b. Ask one question at a time b. Communication: Verbal, Non-verbal, Therapeutic i. Verbal: What you say to the patient ii. Non-verbal – patients are more perceptive to this (how you act towards/around the patient): Facial expressions, tone, posture, appearance, movement, eye contact, gestures, iii. Therapeutic **1. What you do for the patient to make them feel more comfortable
- What you do to alleviate symptoms, pain, and incorporate holistic care, i.e. accommodating the patients physical, psychological, spiritual and social needs a.** Soothing music, b. Speak in a soothing tone **c. Definitions and Examples of Signs and Symptoms
- Signs:** What you see i.e. Dislocated joint ii. Symptoms (subjective) 1. What the patient feels i.e. older patients shrug off pain as a symptom of them getting older à Pain (subjective) **IV. Vital Signs a. Temperature i. Sites
- Oral** – 96.8-100. a. under the tongue 2. Temporal – 98.2-98. a. Lateral to hairline 3. Tympanic - 98.2-98.
i. Blood Pressure
1. BP: SBP <120 – DBP< a. Abnormal **i. Stage 1 HTN SBP 140 - 159 ii. Stage 2 HTN DBP 90 - 99 iii. Hypotension: SBP <
- Respirations** a. 12 - 20 breaths/minute i. Abnormal 1. Bradypnea <12 breaths/min **2. Tachypnea >20 breaths/min ***older adults – 12 - 18
- Pulse** a. 60 - 100 bpm b. Regular rhythm i. Sinus rhythm is common in children and young adults c. Strength i. 2+ - normal, equal bilateral d. Abnormal i. Bradycardia <60bpm ii. Tachycardia >100 bpm iii. Pulse strength – 0=absent, 1+=diminished, 3+=strong, 4+=bounding 1. Temp. a. 96.8 – 100.4F V. Health History a. Purpose i. Build a database of the patient 1. Includes past and current health history a. Include family history b. Functional aids c. Perception of health b. Review of Systems General health Skin, hair, nails Head & neck Eye and ears Nose, mouth, throat, & sinus Breast & regional lymphatics Respiratory Cardiovascular Peripheral vascular Abdominal/gastrointestinal Musculoskeletal Neurologic Hematologic endocrine Genito-urinary/sexual health i. Be specific when stating if something is wrong or the absence of symptoms ii. REVIEW COMPREHENSIVE HH **c. Spiritual, Cultural, Nutritional Assessment
- Be aware of cultural biases and cultural norms
- Do not disregard someone else’s culture and beliefs when they seek treatment unless certain their cultural practices are causing harm a. May need close family and/or community leader to intervene b. If cultural practices are causing harm, work with them patient so they will either gradually or slow activity d. BMI
i. Normal and abnormal ranges
1. Normal BMI – 18.5-24. 2. Overweight – 25 - 29. 3. Obese – 30+ ii. Macronutrients and Calories 1.** Carbohydrates 2. Proteins 3. Fats 4. Calories e. Smoking Pack Years i. Divide total numbers of cigarettes smoked by 20, mult. Total number of years smoked Pack years of smoking To calculate smoking pack-years
- Divide the number of cigarettes smoked per day by 20 (the # of cigarettes in a pack)
- then multiply by the number of years smoked. E.g. (70 cigarettes a day divided by 20 cigarettes/pack) multiply by 10 years = 35 pack- year VI. Pain assessment a. OLDCARTS i. Onset ii. Location iii. Duration iv. Character v. Aggravating factors vi. Relieving factors vii. Treatment viii. severity b. Ask for intensity: 0 - 10 c. How does it affect ADL’s? d. Aching or throbbing, changes w/ movement position and weight (superficial)– nociceptive pain e. Shooting or burnings (deep) – neuropathic pain f. Scales i. CRIES 1. < 6 months 2. component: crying, increased vital signs, expression, sleepless, requires O ii. FLACC 1. 2 months – 7 years 2. look at movement of legs, activity, and face iii. FACES 1. 3 years and older 2. uses pictures of faces to rate pain: 0 to 5 rating **iv. Numeric
- 8 years and older
- 0 to 10 numeric scale VII. Physical Assessment a. Techniques i. Inspection 1.** Assess for size, color, symmetry using sight ii. Palpation 1. Assess for temp., texture, tenderness, size a. Tender areas are assessed LAST
d. check AP diameter; ratio 1:
2. Palpate a. PALPATE FOR SYMMETRIC CHEST EXPANSION b. palpate for tenderness and masses (posterior) c. tactile fremitus - assess for symmetry (posterior) 3. Percuss a. percuss lungs 4. Auscultation a. auscultate all lung sounds; bilateral in "S" pattern or ladder pattern (posterior) **c. Normal and Abnormal Findings: Inspection, Palpation, Percussion, Auscultation i. Normal
- Anterior & Posterior a. Inspection** i. SYMMETRIC LUNG EXPANSION - POSTERIOR AND ANTERIOR ii. straight spinous process iii. thorax is symmetric (expanding) iv. color consistent with ethnicity v. ribs sloping downward at 45 ∘ vi. effortless breathing vii. AP diameter 1: b. Palpation i. tactile fremitus
- vibrations decrease as you go down
- no tenderness, masses, or lumps ii. Abnormal c. Percussion i. resonance is low pitched, clear, hollow - dull sounds over liver and heart, tympany over stomach d. Auscultation i. bronchial (trachea) ii. bronchovesicular (over large airways) iii. vesicular (over peripheral areas of the lungs) 1. Inspection a. Visible effort to breathe & use of accessory muscles b. ANTERIOR i. deviated thorax
- lung & trachea deviation
- lung deviated to left – trachea deviates to right (& visa versa) ii. AP diameter equal/barrel chest iii. hypertrophied neck muscles
- trapezius & sternomastoid iv. tripod position (standing or sitting) v. lesions vi. CYANOSIS vii. Chest excavatum (sternum sunken in) viii. Pectus carinatum (sternum sticks out) c. POSTERIOR i. SPINOUS PROCESS NOT STRAIGHT (S-SHAPED CURVATURE)
ii. KYPHOSIS – “hunch back” iii. CYANOSIS – blue color iv. SCOLIOSIS - move laterally
- Reduce lung volume 2. Palpate a. UNEQUAL CHEST EXPANSION (atelectasis) b. DECREASED FREMITUS (where there should be normal fremitus) i. obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema (over obstruction). c. INCREASED FREMITUS (where there should be decreased fremitus - compression or consolidation of lung tissue, i.e. lobar pneumonia) i. Increases size of lungs ii. Liquid in the lungs d. CREPITUS (coarse crackling sensation) 3. Percussion a. dullness over lung fields- tumor, pneumonia b. hyperresonance - pneumothorax, emphysema (too much air present) 4. Auscultation a. crackles/rales (bubble sounds - pneumonia & pulmonary edema) b. wheezes (whistling musical sounds) c. rhonchi (course rumbling - asthma and emphysema) d. pleural friction rub (grating, rubbing sounds) e. stridor (sounds like a rhino) f. decreased or absent breath sounds (obstruction of bronchial tree, loss of elasticity, obstruction, i.e. pneumothorax, pleural effusion [water in pleural cavity]) g. NOTE ANY ADVENTITIOUS SOUNDS (short popping) d. Breath Sounds: Normal and Abnormal findings and clinical significance i. Normal 1. bilateral clear, high pitched, loud breath sounds over **trachea (bronchial)
- medium** pitched vesicular breath sounds over **mainstream bronchi (bronchovesicular)
- soft** , breezy low-pitched vesicular breath sounds over **peripheral lung fields (vesicular) ii. Abnormal
- crackles/rales** : (bubble sounds - pneumonia & pulmonary edema) 2. wheezes : (whistling musical sounds) 3. rhonchi : (course rumbling - asthma and emphysema) 4. pleural friction rub : (grating, rubbing sounds) 5. stridor : (sounds like a rhino) 6. Clubbing : e. Voice Sounds: Normal and Abnormal findings and clinical significance i. Normal: transmission is soft, muffled and indistinct ii. Abnormal: sk the patient to speak when auscultating lungs - performed if you suspect lung pathology on previously collected data 1. bronchophony a. voice heard clearly when auscultating b. present when consolidation is suspected (filled w/ fluid instead of air) 2. Egophony: ask patient to say "e" sounds – you hear “a” sound; the sounds will be heard clearly while auscultating 3. whispered pectoriloquy
a. Not able to palpate any lifts, heaves, thrills, masses
3. Auscultation a. regular rhythm - sinus arrhythmia occurs normally in young adults & children b. Use bell of stethoscope on trachea for i. No blowing sounds c. Apical pulse i. Use diaphragm – alternate to bell if can’t hear 1. Not palpable if lungs are hyperinflated or pulmonary emphysema d. S1 at apex; S2 at base **ii. Abnormal
- Inspection a.** Distended jugular vein i. Measure if vein visibly distended 2. Palpation a. Palpate abdomen if jugular vein is distended b. Lifts, Heaves, and thrills on palpation i. Occurs w/ right ventricular hypertrophy, pulmonic valve disease, pulmonic HTN, chronic lung disease (COPD) 3. Auscultation a. Bruit sounds over trachea b. Diminished heart sounds (S1 and S2) i. Due to increase of air or tissue between heart and stethoscope (i.e. hyperinflated lung, obesity, pericardial fluid) c. Extra heart sounds – S3 & S i. Murmurs
- harsh, rumbling, blowing sounds - blood flow across a defective valve
- May sometimes only be heard on the left side a. normal valve - occur due to exercise, pregnancy, or thyrotoxicosis b. stenotic valve c. backward flow – regurgitate valve d. abnormal openings in chambers ii. Apical pulse
- Left ventricular enlargement displaces apical impulse a. Apical pulse occupies more space **iii. Splits
- Fixed split** a. Affect by respiration b. Happens w/ atrial septal defect 2. Paradoxical split a. Sounds fuse on inspiration; split on expiration iv. Midsystolic click
- S3 and S4 occur in diastole (S1) v. systolic (S2)
- ejection click - in early systole vi. diastolic (S1)
- aortic prosthetic valve sounds
- midsystolic click - in early systole
d. Heart Sounds and Murmurs: Normal and Abnormal findings and clinical significance i. Normal
1. S1 (apex) and S2 (base) sounds ii. Abnormal a. Extra heart sounds - S3 and S i. Murmurs
- harsh, rumbling, blowing sounds - blood flow across a defective valve
- May sometimes only be heard on the left side a. normal valve - occur due to exercise, pregnancy, or thyrotoxicosis b. stenoic valve c. backward flow – regurgitate valve d. abnormal openings in chambers **ii. Splits
- Fixed split** a. Affect by respiration b. Happens w/ atrial septal defect 2. Paradoxical split a. Sounds fuse on inspiration; split on expiration iii. Midsystolic click
- S3 and S4 occur in diastole (S1) a. Jugular Venous Pressure: Normal and Abnormal findings and clinical significance i. Normal 1. Non-distended jugular vein a. Contour is smooth w/ brisk upstroke & slower downstroke **ii. Abnormal
- Distended jugular vein a.** Measure if vein visibly distended b. Palpate abdomen if jugular vein is distended c. Bruit sounds over trachea
6. Allen’s Test a. Checking for occlusion i. Normal color should return w/in 7 seconds 7. Calf sizes – checking for DVT a. If there is a visible difference in size, measure w/ paper measure around widest part of the leg i. Normal both legs should be the same iii. Auscultate 1. Bruit sounds c. Techniques for assessing the lymphatic system i. Palpation 1. Check for swollen, tender, firm/hard masses d. Arterial versus Venous Insufficiency i. Venous - Brown/bluish color; warm to touch 1. Ulcers a. Due to chronic incompetent valve ii. Arterial - red in color; cool to touch 1. Ulcer a. Calcification of arterial wall (arteriosclerosis) e. Edema i. Press along tibia for 5 seconds 1. Normally no indentation – 0 grade f. Normal and Abnormal Findings: Clinical Significance i. Normal 1. Normally not felt on palpation ii. Abnormal 1. swollen, tender, firm/hard masses 2. Raynaud’s phenomenon a. Progressive tricolor change in response to stress, vibration & cold 3. Lymphedema a. i.e. Lymph nodes enlarge when breast tissue is removed 4. Neuropathic ulcer a. MD hastens arterial ulcer i. Interrupts blood flow 5. Superficial varicose veins a. Dilation of veins caused by obesity and multiple pregnancies i. Increases venous pressure 6. DVT a. Deep vein is occluded by thrombus 7. Aneurysm a. Sac formed in the arterial wall XI. Abdomen a. Anatomical landmarks for assessing the abdomen i. RLQ, RUQ, LUQ, LLQ Right Upper Quadrant (RUQ) Left Upper Quadrant (LUQ) Liver, Gallbladder, Duodenum, Head of pancreas, Right kidney and adrenal, Hepatic flexure of colon, Part of ascending and transverse colon Stomach, Spleen, Left lobe of liver, Body of pancreas, Left kidney and adrenal, Splenic flexure of colon, Part of transverse and descending colon Right Lower Quadrant (RLQ) Left Lower Quadrant (LLQ)
Cecum Appendix Right ovary and tube Right ureter Right spermatic cord Part of descending colon, Sigmoid colon, Left ovary and tube, Left ureter, Left spermatic cord Midline Aorta, Uterus (if enlarged), Bladder (if distended) b. Techniques for assessing the abdomen - make sure room is warm, diaphragm warm, hands warm, empty bladder i. Inspection
1. assess for contour, lesions, scars, striae, distention, visible pulsations & symmetry 2. sunken umbilicus 3. even and smooth, good turgor, homogenous color ii. Auscultation 1. bowel sounds (peristalsis) in all 4 quadrants - use diaphragm a. irregular, cascading sounds iii. Percussion 1. tympany over stomach and small & large intestines a. air rises to the top b. dullness over solid organs 2. determine size & location of liver iv. Palpation **ask questions to patient while palpating for areas where they are tender 1. assess for guarding, rigidity, masses and tenderness 2. use low soothing voice, breathing exercise while asking questions 3. examine painful areas last 4. Kidneys a. palpate at costovertebral angle (posterior) 5. Fluid wave test a. test for ascites on abdomen **c. Normal and Abnormal Findings: Clinical Significance i. Normal
- Inspection a.** Symmetry b. sunken umbilicus c. even and smooth, good turgor, homogenous color d. no lesions, tenderness, masses, pulsations 2. Auscultation a. presence of peristalsis - bowel sounds 3. Percussion a. tympany - stomach, bladder, small intestine, colon b. dullness over solid organs; liver, pancreas, spleen, kidneys, ovaries, adrenal glands 4. Palpation a. Perform light and deep palpation i. No tenderness or masses on internal organs b. No change on fluid wave test i. No ascites present. **ii. Abnormal
- Inspection a. Asymmetry**
2. iliopsoas test a. leg raised; then push down - pain - appendicitis 3. obturator test ii. After abdominal surgery 1. assess for bowel sounds (peristalsis) a. sounds may not be heard iii. Subjective Questions 1. complains of abdominal pain a. questions to ask i. 1st question - Do you have any pain? ii. pain scale - rate from 0 to 10 iii. location? iv. onset? v. characteristic - sharp? Dull? vi. what makes the pain better? vii. what makes the pain worse? viii. how long have you had the pain? ix. frequency? x. on 1 spot? Does it radiate? b. Questions re: appetite
i. how is your appetite? ii. any dysphagia? iii. nutritional assessment
1. 4 hr food recall iv. food intolerance? 1. allergies? Food sensitivities? v. nausea? Vomiting? vi. abdominal history The anatomic location of the organs by quadrants is: Right Upper Quadrant (RUQ) Left Upper Quadrant (LUQ) Liver, Gallbladder, Duodenum, Head of pancreas, Right kidney and adrenal, Hepatic flexure of colon, Part of ascending and transverse colon Stomach, Spleen, Left lobe of liver, Body of pancreas, Left kidney and adrenal, Splenic flexure of colon, Part of transverse and descending colon Right Lower Quadrant (RLQ) Left Lower Quadrant (LLQ) Cecum, Appendix, Right ovary and tube, Right ureter, Right spermatic cord Part of descending colon, Sigmoid colon, Left ovary and tube, Left ureter, Left spermatic cord Midline Aorta, Uterus (if enlarged), Bladder (if distended) **Abdominal Distention
- Obesity** : - Inspection - Uniformly rounded. Umbilicus sunken (it adheres to peritoneum; layers of fat are superficial to it). - Auscultation - Normal bowel sounds. - Percussion - Tympany. Scattered dullness over adipose tissue. - Palpation - Normal. May be hard to feel through thick abdominal wall. - Air or Gas : - Inspection - Single round curve. - Auscultation - Depends on cause of gas (e.g., decreased or absent bowel sounds with ileus); hyperactive with early intestinal obstruction. - Percussion - Tympany over large area. - Palpation - May have muscle spasm of abdominal wall.
- Ascites : - Inspection - Single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin due to recent weight gain; increase in abdominal girth. - Auscultation - Normal bowel sounds over intestines. Diminished over ascitic fluid. Percussion- Tympany at top where intestines float. Dull over fluid. Produces fluid wave and shifting dullness. - Palpation - Taut skin and increased intra-abdominal pressure limit palpation.
- **Ovarian Cyst (Large):
- Inspection** - Curve in lower half of abdomen, toward midline. Everted umbilicus. Auscultation- Normal bowel sounds over upper abdomen where intestines pushed superiorly. - Percussion - Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wave and shifting dullness. - Palpation - Transmits aortic pulsation, whereas ascites does not.
- **Pregnancy:
- Inspection** - Single curve. Umbilicus protruding. Breasts engorged.
- Enlarged Gallbladder : An enlarged, tender gallbladder suggests acute cholecystitis. Feel it behind the liver border as a smooth and firm mass like a sausage, although it may be difficult to palpate because of involuntary rigidity of abdominal muscles.
- Enlarged Spleen: Because any enlargement superiorly is stopped by the diaphragm, the spleen enlarges down and to the midline
- Enlarged Kidney : Enlarged with hydronephrosis, cyst, or neoplasm.
- Aortic Aneurysm : Most aortic aneurysms (>95%) are located below the renal arteries and extend to the umbilicus. a. Bowel Sounds: Normal and Abnormal findings and clinical significance Abnormal Bowel Sounds
- Succussion Splash : Unrelated to peristalsis, this is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side.
- Hypoactive Bowel Sounds : Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia.
- Hyperactive Bowel Sounds : Loud, gurgling sounds, “borborygmi,” signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus. e. Abdominal pain: Assessment and Clinical Significance Common Sites of Referred Abdominal Pain When a person gives a history of abdominal pain, the pain's location may not necessarily be directly over the involved organ because the human brain has no felt image for internal organs. Rather, pain is referred to a site where the organ was located in fetal development. Although the organ migrates during fetal development, its nerves persist in referring sensations from the former location. The following are examples, not a complete list. Liver: Hepatitis may have mild-to-moderate dull pain in right upper quadrant (RUQ) or epigastrium, along with anorexia, nausea, malaise, low-grade fever. Esophagus: Gastroesophageal reflux disease (GERD) is a complex of symptoms of esophagitis, including burning pain in midepigastrium or behind lower sternum that radiates upward, or “heartburn.” Occurs 30 to 60 minutes after eating; aggravated by lying down or bending over. Gallbladder : Cholecystitis is biliary colic, sudden pain in RUQ that may radiate to right or left scapula and that builds over time, lasting 2 to 4 hours, after ingestion of fatty foods, alcohol, or caffeine. Associated with nausea and vomiting and with positive Murphy sign or sudden stop in inspiration with RUQ palpation. Pancreas : Pancreatitis has acute, boring midepigastric pain radiating to the back and sometimes to the left scapula or flank, severe nausea, and vomiting. Duodenum : Duodenal ulcer typically has dull, aching, gnawing pain; does not radiate; may be relieved by food; and may awaken the person from sleep. Stomach : Gastric ulcer pain is dull, aching, gnawing epigastric pain, usually brought on by food and radiates to back or substernal area. Pain of perforated ulcer is burning epigastric pain of sudden onset that refers to one or both shoulders. Appendix : Appendicitis typically starts as dull, diffuse pain in periumbilical region that later shifts to severe, sharp, persistent pain and tenderness localized in RLQ (McBurney point). Pain is aggravated by movement, coughing, deep breathing; associated with anorexia, then nausea and vomiting, fever.
Kidney : Kidney stones prompt a sudden onset of severe, colicky flank or lower abdominal pain. Small intestine : Gastroenteritis has diffuse, generalized abdominal pain with nausea, diarrhea. Colon: Large bowel obstruction has moderate, colicky pain of gradual onset in lower abdomen and bloating. Irritable bowel syndrome (IBS) has sharp or burning cramping pain over a wide area; does not radiate. Brought on by meals; relieved by bowel movement. XII. Skin, Hair, and Nails a. Techniques for assessing the skin, hair, and nails i. Hair
1. Even distribution of hair 2. Check for presence of pests 3. Smooth, thick texture **ii. SKIN
- Inspect a. Color** – even pigmentation w/ no lesions, nevi, warm to touch, dry smooth and even b. No presence of lesions or dehydration **c.
- Palpate a.** Temperature b. Edema i. Press down on tibia 1. Note grade of edema c. Dehydration i. Pinch skin on clavicle – note tenting **iii. Nails
- Inspect a.** Pink nailbeds b. Note clubbing c. Check for clubbing or deformities d. Discoloration e. Clean? 2. Palpate a. Press down on nail bed – checking capillary refill – 2 - 3 seconds b. Normal and Abnormal Findings: Clinical Significance i. Normal 1. Skin 2. Nails a. Translucent nail plate; pink nail bed b. Smooth surface 3. Thin, thick, curly straight – should be shiny **ii. Abnormal
- Skin a. Color** i. Pallor – anemia, shock, circulation problems (whitish or pink)
- Brown skin appears yellow-brown, dull
- Black sin appears ashen, gray, dull – skin loses its glow ii. Cyanosis – hypoxia
- Appears dusky blue iii. Jaundice – hepatic dysfunction or RBC destruction
- Yellow in sclera, hard palate, mucous membrane & skin
