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Skin, Hair & Nail Assessment Flashcards

(21 cards)

1
Q

color assessment (4)

A

1) pallor: white color to skin
- hypertension, insufficient pre-load
- in mucous membranes
2) cyanosis: blueish color to lips & nails
- hypoxia (low-oxygen)
3) jaundice: yellow in sclera (supposed to be white)
- excess belly reuben
4) erythema: redness
- edema, (palpate for heat & warmth)
- heels, sacrum

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2
Q

how to assess dark-skinned patients

A

assess areas where pigmentation occurs the least

  • pallor in mucous membranes
  • erythema by palpating for warmth & heat
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3
Q

moisture assessment (5)

A

1) hydration
2) diaphoresis
3) flaking, scaling, or crusting
4) dryness
5) excessive dryness

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4
Q

hydration

moisture assessment

A
  • dryness

- oiliness

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5
Q

diaphoresis

moisture assessment

A

= sweating

-perspiration

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6
Q

flaking, scaling, or crusting

moisture assessmnt

A

= dehydration

  • more common in elderly
  • overuse of soap
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7
Q

dryness

moisture assessmnt

A
  • dehydration
  • smoking
  • stress
  • sun exposure
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8
Q

excessive dryness

moisture assessmnt

A
  • eczema (excessive dryness & itching)

- dermatitis (inflammation of dermal layer of the skin)

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9
Q

temperature assessment

  • dependent on what
  • best assessed how
  • always compare what
  • be alert to what
A
  • dependent on amount of blood circulating through the dermis
  • best assessed through PALPATION
  • compare symmetrical body parts
  • be alert to areas of warmth and erythema (could be stage 1 pressure ulcer)
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10
Q

Braden scale assesses what

-max & how low for a nursing intervention

A
  • scale for pressure sores
  • max 23
  • 18 or lower -> intervention
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11
Q

6 components of Braden scale scoring

A
1) sensory perception
ex/ dementia, paralysis on one-side
2) moisture
ex/ person in diaper
3) activity level
ex/ walk=4   bed rest=1
4) nutrition: usual food intake pattern
5) friction & shearing: mvmnt in bed
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12
Q

texture assessment

A

(how skin feels)

-smooth, rough, thin, thick, tight, indurated, scarred, wrinkled

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13
Q

turgor assessment (3)

A

1) elasticity
- edema, dehydration, age
2) pink skin & release fold on forearm & sternal bone
3) tenting: poor skin turgor/dehydration

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14
Q

vascularity assessment

A

-observe for reddened, pink or pale areas

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15
Q

petechiae

A
  • red or purple spots
  • may indicate blood clotting disorders (coagulation: can’t clot properly), drug reactions, or liver disease
  • small hemorrhages
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16
Q

edema assessment

  • edema may be secondary to what
  • more common where
A
  • observe and palpate for fluid build up in tissues
  • secondary to: direct trauma or impaired venous return = PRELOAD
  • common in dependent areas
17
Q

edema: if indentation remains after 5 seconds its called what
- whats the scale

A

-pitting edema
+1 = 2mm deep
+2 = 4mm
+3 = 6mm

18
Q

melanoma is what

-what do you use to assess warning signs

A

-deadliest form of skin cancer
-begins as small, mole like growth
ABCD:
-asymmetry
-border iregularity
-color variation from blue to black
-diameter greater than 6 mm

19
Q

hair assessment

A
  • observe

- color, quantity, thickness, texture, hirsutism (abnormal hair growth: women w/ facial hair)

20
Q

clubbing indicates what

A
  • COPD

- chronic low oxygen levels

21
Q

cap refill assessment

-normal & abnormal

A
  • press on nail & release
  • normal: 2 seconds
  • peripheral vascular disease
  • arterial blockage
  • heart failure
  • shock