Skin, Hair, & Nails Flashcards Preview

Assessment > Skin, Hair, & Nails > Flashcards

Flashcards in Skin, Hair, & Nails Deck (85)
Loading flashcards...
1

Name and describe the functions of the skin. Hint: There are a lot!

–Protector and barrier between internal organs and external environment
–Barrier against foreign body intrusions (against invading bacteria and foreign matter)
–Transmits sensation (nerve receptors allow for feelings of temperature, pain, light touch and pressure)
–Vitamin production (exposure to UV light allows for the conversion of substances necessary for synthesizing vitamin D, necessary to prevent osteoporosis, rickets)
–Regulates body temperature (regulates heat loss)
–Helps regulate fluid balance: (absorbs water, prevents excessive water & electrolyte loss; slows loss up to 600 ml daily by evaporation)
–Immune response function (inflammatory process)

2

What does cephalocaudal mean?

Head to toe

3

Skin assessment involves both ____________ and ___________ simultaneously.

inspection (olfactory), palpation

4

What kind of lighting is best for a skin assessment?

Natural light, esp for things like jaundice

5

What are some tools needed for a full skin assessment?

–Penlight
–Centimeter ruler
–Magnifying glass
–Gloves (if assessing open or draining lesions)

6

What is some of the subjective data gathered from your patient in a skin assessment?

–Family history
–Previous history of skin disease
–Medications
–Current health status
–Environmental or occupational hazards
–Self-care/health promotion behaviors

7

Some s/s to look for in a skin assessment?

–Rash or lesion
–Change in pigmentation
–Change in mole
–Excessive dryness or moisture
–Pruritus
–Excessive Bruising

8

What does a skin assessment tell us?

–Local tissue damage
–Oxygenation
–Circulation
–Nutrition
–Hydration

9

What are some ways to describe the hue of the skin?

–Pallor
–Cyanosis
–Jaundice
–Erythema
–Hyperpigmentation
–Hypopigmentation – vitiligo

10

What is vitiligo?

Hypopigmentation

11

What is pallor describing?

Lack of color

12

What is erythema describing?

Redness

13

What does induration mean?

Hardness

14

What are we palpating for with skin?

•Increased warmth
•Induration (hardness)
•Tautness

15

Where does jaundice occur?

Initially occurs in mouth on mucous membranes and at junction of soft and hard palates and sclera. Then spreads over body.

16

How does cyanosis appear on darker-toned skin?

Ashen gray

17

How does pallor appear on darker-toned skin?

Ashen gray or yellowish brown (brown skin)

18

How does erythema appear on darker-toned skin?

Hyperpigmentation; rely on palpation of warmth or edema

19

What is petechiae?

Small size pinpoint hemorrhages (purplish in lighter skin, usually invisible with more melanated skin tones).

20

How does petechiae appear in darker-toned skin?

Usually invisible; check oral mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.

21

How does jaundice appear on darker-toned skin?

Reliable on sclera, hard palate, palms and soles.

22

How does ecchymosis appear on darker-toned skin? Light-toned?

Difficult to see, check mouth or conjunctiva
Purplish to yellow-green

23

What is ecchymosis?

A discoloration of the skin resulting from bleeding underneath, typically caused by bruising.

24

How does a brown-tan cortisol deficiency (increased melanin) present in darker and lighter skin tones?

Darker: Easily masked
Lighter: Bronze; tan to light brown

25

How should you describe lesions?

•Be descriptive, size shape texture
•Color is important
•Distribution
•Configuration
•Use proper terminology

26

Configuration of Lesions: What does linear describe?

Occurring in a straight line

27

Configuration of Lesions: What does linear discrete describe?

Lesions stay separate

28

Configuration of Lesions: What does linear confluent describe?

Lesions that run together

29

Configuration of Lesions: What does arciform describe?

Arcs or rings

30

Configuration of Lesions: What does annular describe?

Ringlike with raised borders around round, flat clear center

31

Configuration of Lesions: What does circunate describe?

Circular

32

Configuration of Lesions: What does clustered aka grouped describe?

Several lesions grouped together (duh)

33

Configuration of Lesions: What does serpiginous describe?

With wavy borders, snakelike aka gyrate (example: ringworm)

34

Primary lesions: What is a macule?

Flat, color change, up to <1 cm
ex: Freckles, measles

35

Primary lesions: What is a plaque?

Raised patches, elevated plateau regions, larger than 1 cm. Well defined. Can be caused by psoriasis, other issues.

36

What does circumscribed mean?

Well defined borders

37

Primary lesions: What is a papule?

Next step after a macule but raised, circumscribed, elevated, solid. <1 cm
ex: Mole

38

Primary lesions: What is a nodule?

Circumscribed, solid
ex: Cyst

39

Primary lesions: What is a vesicle?

Elevated lesion up to 1 cm, serous fluid filled
ex: Herpes

40

Primary lesions: What is a pustule?

Same as vesicle (elevated lesion) but filled with pus

41

Primary lesions: What are urticari/wheals?

Raised, superficial, transient errythmia. Usually itchy.
ex: Hives, allergic rxn

42

What is a secondary lesion?

A change that comes from a primary lesion.

43

Secondary lesions: What are scales?

Shedding dead skin cells, may be dry and loose or oily and adherent. You itch and it becomes scaly.
Example: Psoriasis

44

Secondary lesions: What is a fissure?

Linear cleft in the skin extending through epidermis into the dermis, they usually occur when skin is dry and thickened. Often seen in heels, between fingers and toes, sides of mouth.

45

Secondary lesions: What is excoriation?

Loss of outer skin layers from itching or rubbing. Example: Scratched insect bite

46

Secondary lesions: What is erosion?

Loss of epidermis that does not extend into dermis. Example: Ruptured chicken pox vesicle.

47

Secondary lesions: What is a keloid formation?

Palpable, raised overgrowth of collagen
Example: from around a scar

48

Name three other things we look for when assessing skin.

– Edema
– Moisture
– Vascular changes

49

Vascular Lesions: What is hemangioma?

Benign proliferation of blood vessels in the dermis (also: a bright red birthmark that shows up at birth or in the first or second week of life. It looks like a rubbery bump and is made up of extra blood vessels in the skin.)

50

Vascular Lesions: What are petechiae?

Tiny, pinpoint hemorrhages, superficial bleeding from capillaries (less than 3 mm) under skin. Can be seen with DIC, viral meningitis, can be localized from an injury.

51

Vascular Lesions: What are purpura?

Flat macular hemorrhage under skin, does not blanche, 3-10 mm, possibly raised. Burst at the capillary level. Seen in trauma.

52

Contusion and ecchymiosis are both words that mean:

Bruise

53

What are the ABCDE s/s for skin assessment danger signs?

Asymmetry
Border (irregularity)
Color change
Diameter
Elevation & enlargement

54

While checking the integrity of the skin, what are things we are looking for?

– Skin tears (look when rolling, ambulating, helping to the bathroom)
– Cleanliness (great time to assess during bed bath)
– Tattoos and piercings (make sure piercings are off for MRI and sx!)

55

What are some things palpation helps assess?

● Confirms the size of the lesions and determines
whether they are flat or raised
● Skin temperature (assessed with the back of the hand)
● Turgor (the amount of skin elasticity)
● Edema (covered in CV)

56

What side of your hands do you use to palpate for skin temperature?

Dorsal

57

What does skin turgor assess?

Hydration status

58

What is hirsutism?

Excessive growth of body hair, which is one manifestation of hormonal imbalance.

59

Name some things to assess when examining at hair:

Color, distribution, texture. Also: cleanliness, distribution, quantity, and quality.

60

What is pediculosis capitis?

When nits (lice larvae) are attached to the hair shaft and are difficult to remove.

61

What is alopecia?

Absence or loss of hair

62

Nail assessment: What are some things to look for?

● Dystrophic nails (different textures)
● Color of nail plate
● Nail shape changes
● Nail thickness, consistency, lesions

63

What is acute or chronic paronychia?

Infection of the epidermal layer of the nail

64

Nail color is usually pink but in individuals with higher
melanin can have _____________.

Brown to black bands

65

Longitudinal ridges, a common variation, are often caused by what?

Zinc deficiency.

66

What do clubbing of nails indicate?

Long term decrease in O2 (chronic hypoxia)

67

What is this?

Plaques

68

What is this?

Vesicle

69

What is this?

Wheals/Urticaria

70

What is this?

Papules

71

What is this?

Pustules

72

What is this?

Nodules

73

What is this?

Macules

74

What does serosanguinous drainage look like?

It is thin, like water. It usually has a light red or pink tinge, though it may look clear in some cases.

75

What does sanguineous drainage look like?

Sanguineous drainage refers to the leakage of fresh blood produced by an open wound. Can look beefy, like jelly, clots.

76

What is eschar?

• Dead tissue in a full thickness wound
• Brown, tan, black, thick, dry, leathery
• Not to be confused with a scab that covers a partial thickness or superficial wound, rusty brown crust

77

What is slough?
 

• Wet, stringy, moist, yellow/white
• Fibrotic or necrotic tissue
• Needs to be removed for wound healing to take

78

What do you want to measure with wounds?

• Head to toe
• Side to side
• Depth
• Clock face for undermining or tunnels

79

Name four types of woudns

A. Incision

B. Abrasion

C. Contusion (just bruising)

D. Hematoma (can palpate fluid)

80

Wha does a Stage 1 pressure ulcer look like?

• Non-blanchable redness

• Color

• Painful

• Different than adjacent tissue

81

Wha does a Stage 2 pressure ulcer look like?

• Partial-thickness loss of dermis

• Red-pink wound bed

• Intact or open/ruptured serum filled blister

• Shiny or dry

82

What does a stage 3 pressure ulcer look like?

• Full-thickness tissue loss

• Subcutaneous fat visible

• Slough

• Undermining and tunneling

83

What does a stage 4 pressure ulcer look like?

• Full-thickness tissue loss with exposed bone, tendon, or muscle.

• Slough or eschar

• Undermining and tunneling

84

What makes a pressure ulcer unstageable?

• Full-thickness tissue loss

• Slough present

• Eschar

• WE ARE UNABLE TO SEE HOW DEEP IT IS

85