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Health Assessment Lecture > Assessing The Integumentary System > Flashcards

Assessing The Integumentary System Flashcards

1
Q

● Heaviest single organ of the body
● 16% of body weight
● Includes appendages such as hair follicles and sebaceous glands

A

Skin

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2
Q

● Three layers: epidermis, dermis, subcutaneous layers
● Protect underlying structures from physical trauma and UV radiation
● Essential in maintaining body temperature, fluid and sensation
● Involved in absorption and excretion, immunity, and synthesis of vitamin D from the sun

A

Skin

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3
Q

Layers of the Skin

A
  1. Epidermis
  2. Dermis
  3. Subcutaneous Layer
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4
Q

Identify the Layer of Skin
● Outer visible layer
● Avascular
● Contains keratin

A

Epidermis

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5
Q

Identify the Layer of Skin
● Made up of proteins and mucopolysaccharides
● Contains nerve tissues, blood vessels,
sweat and sebum glands, and hair follicles

A

Dermis

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6
Q

Identify the Layer of Skin
● Made up of fatty connective tissue

A

Subcutaneous Layer

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7
Q

● Made up of keratinized cells
● Grows from hair follicles supplied by blood vessels
● Types: Vellus and Terminal hair
● Provides protection by covering the scalp and filtering dust and debris away from the nose, ears, and eyes

A

Hair

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8
Q

Types of Hair

A
  1. Vellus hair
  2. Terminal hair
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9
Q

Identify the types of Hair
● Short, pale, and fine hair

A

Vellus hair

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10
Q

Identify the types of Hair
● Dark and coarse
● Found on the scalp, brows, legs, axillae
and perineum

A

Terminal hair

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11
Q

● Made up of hard, keratinized cells and grow from a nail root under the cuticle
● Protect the distal ends of the fingers and toes and aid in picking up objects
● Other structures: free edge, nailbed, lunula
● Vascular supply is on the nailbed; gives the nail a pink color
● Fingernails: grow approximately 0.1mm daily
● Toenails grow more slowly

A

Nails

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12
Q

It has Eccrine glands and Apocrine glands

A

Sweat glands

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13
Q

This gland is….
- Widely distributed, open directly onto
the skin surface
- Help control body temperature

A

Eccrine glands

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14
Q

This gland is….
▪ found in the Axillary and genital regions
▪ surfaces into hair follicles
▪ Responsible for adult body odor due to
bacterial decomposition

A

Apocrine glands

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15
Q

Gland that produce fatty substance secreted onto the skin surface through the hair follicles and lubricates the hair shaft

A

Sebaceous gland

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16
Q

Interaction with other Body Systems:
- The Respiratory System

A

If respiration is impaired, alterations is the skin are most often evident through
the development of cyanosis

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17
Q

Bluish discoloration of the skin, as hemoglobin becomes unsaturated with oxygen

A

CYANOSIS

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18
Q

Respiratory System Fails Manifestations: Cyanosis

A

Peripheral and Central Cyanosis

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19
Q

Respiratory System Fails Manifestations: Cyanosis

Occurs when O2 saturation is <80% and results in diffuse changes in the skin and mucous membranes

A

Central Cyanosis

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20
Q

Respiratory System Fails Manifestations: Cyanosis

Occurs in response to decreased cardiac output Evident in areas of the body such as the nail beds and lips May also be evident when an individual is chilled

A

Peripheral Cyanosis

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21
Q

Manifestations when Respiratory System Fails:
Loss of the normal angle between the nail and nail bed owing to bulbous swelling of the soft tissue of the terminal phalanx of a digit due severe and chronic cardiopulmonary diseases

A

Nail Clubbing

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22
Q

Manifestations when Cardiovascular System Fails:

A
  • Alterations can lead to circulatory impairment and changes in skin color and temperature which may develop Lesions, ulcerations, necrosis, and cyanosis
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23
Q

Manifestations when Gastrointestinal System Fails:

A

body’s ability to excrete toxins is impaired and accumulation of toxins may become
evident in the skin

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24
Q

Manifestations when Gastrointestinal System Fails:
- Yellowish discoloration of the skin due
to bile build-up secondary to impaired
bile secretion

A

Jaundice

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25
Q

Manifestations when Gastrointestinal System Fails:
- Lipid deposits in the skin due to altered
lipid metabolism

A

Xanthomas

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26
Q

Manifestations on skin when there is Vitamin A Deficiency
- abnormally dry,
scaly skin or membranes

A

Xerosis

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27
Q

Manifestations on skin when there is Vitamin A Deficiency
- hyperkeratosis of the skin manifested by red-brown follicular papules that are approximately 2-6mm in diameter, with a central keratotic spinous plug

A

Phrynoderma

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28
Q

Manifestations on skin when there is Riboflavin Deficiency
- chapping and
fissuring of the lips

A

Cheilosis

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29
Q

Manifestations on skin when there is Riboflavin Deficiency
- sore, red tongue

A

Glossitis

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30
Q

Manifestations on skin when there is Vitamin C Deficiency
- It results into purpura, petechiae, and
ecchymosis in the skin and splinter hemorrhages in the nails

A

Capillary fragility

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31
Q

Manifestations on skin when there is Vitamin C Deficiency
- Hair loss can affect just your scalp or your entire body, and it can be temporary or permanent
- can be the result of heredity, hormonal changes, medical conditions or a normal part of aging

A

Alopecia

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32
Q

Manifestations on skin when there is Vitamin C Deficiency
- can occur as a result of scurvy

A

Corkscrew hair

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33
Q

Manifestations on skin when there is Iron Deficiency
- vertical raised lines present on the nails

A

Longitudinal ridges on the nails

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34
Q

Manifestations on skin when there is Iron Deficiency
- spoonlike convexity of the nails

A

Koilonychia

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35
Q

Manifestations on skin when there is Iron Deficiency

A

Thinning of hair

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36
Q

Manifestations on skin when there is Iron Deficiency
- loss of pink color in the palmar creases on the
full open palms

A

Palmar crease pallor

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37
Q

Manifestations on skin when there is Protein Deficiency
- alternating horizontal bands of hypopigmentation of the hair

A

Flag sign

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38
Q

Manifestations on skin when there is Protein Deficiency
- dark, dry kin that splits open when stretched,
revealing pale areas between the cracks

A

Enamel paint skin

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39
Q

Manifestations when Urinary System Fails:

A
  • Alteration in the renal function
    may lead to toxin and fluid
    build-up
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40
Q

Skin Manifestations when Urinary System Fails:
- Tiny, yellow-white urea crystals deposits on the skin resulting in a frosted appearance as sweat
evaporates

A

Uremic frost

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41
Q

Skin Manifestations when Urinary System Fails:
- Impaired renal function may result in fluid retention as manifested by edema

A

Edema

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42
Q

Manifestations when Neurological System Fails:

A
  • place a person at risk for injury
    and discomfort
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43
Q

Manifestations when Endocrine System Fails:

A

Alterations of the endocrine system may affect the skin in myriad ways
- Diabetes
- Thyroid Disease (Hypothyroidism or Hyperthyroidism)
- Adrenal Disease (Hypofunction (Addison’s
Disease) and Hyperfunction (Cushing’s Syndrome)

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44
Q

Thyroid Disease has two types

A

Hypothyroidism and Hyperthyroidism

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45
Q

Thyroid Disease Identify which type:
- The skin is often dry and cool and becomes puffy, with nonpitting edema. It may develop a yellow hue as carotene accumulates The hair becomes dull, brittle, and sparse

A

Hypothyroidism

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46
Q

Thyroid Disease Identify which type:
- The skin is warmer, sweatier, and smoother than usual The nails are thin and brittle and may separate from the nail plate The hair is fine and silky, with patchy hair loss

A

Hyperthyroidism

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47
Q

Adrenal Disease two types

A

Hypofunction (Addison’s Disease) and Hyperfunction (Cushing’s Syndrome)

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48
Q

Adrenal Disease Identify which type:
- Bronze discoloration of the skin
and alopecia

A

Hypofunction (Addison’s Disease)

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49
Q

Adrenal Disease Identify which type:
- Violaceous striae, facial acne, hirsutism, acanthosis nigricans

A

Hyperfunction (Cushing’s Syndrome)

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50
Q

Manifestations when Lymphatic/Immune
System Fails:

A

Impairments in the immune system may result in typical rashes or lesions

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51
Q

Skin Manifestations when Lymphatic/Immune
System Fails:
- exaggerated or inappropriate immunologic responses occurring in response to an antigen or allergen

A

Hypersensitivity reaction

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52
Q

Skin Manifestations when Lymphatic/Immune
System Fails:
- chronic (long-lasting) disease in which the immune system becomes overactive, causing skin cells to multiply too quickly
- Patches of skin become scaly and inflamed, most often on the scalp, elbows, or knees

A

Psoriasis

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53
Q

Skin Manifestations when Lymphatic/Immune
System Fails:
- when immune cells in your skin react to UV light sources, releasing chemicals that inflame your skin

A

Butterfly rash in Systemic Lupus Erythematosus

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54
Q

Collecting Subjective Data: GROWTHS

A

Ask if the patient is concerned about any new growths or rashes

  • “Have you noticed any changes in your skin? Your hair? Your nails?
  • “Have you had any rashes? Sores? Lumps? Itching?”

If the patient reports a new growth, pursue the patient’s personal and family history of skin cancer.

  • Note the type, location, and date of any past skin cancer and ask
    about regular self-skin examination and use of sunscreen
  • Also ask “Has anyone in your family had a skin cancer removed? If
    so, who? Do you know what type of skin cancer?”
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55
Q

Collecting Subjective Data: RASHES

A

Ask about itching – the most important symptom when assessing rashes

  • Does the itching precede the rash or follow the rash?
  • For itchy rashes, ask abut seasonal allergies with itching and watery eyes, asthma, and atopic dermatitis, often accompanied by rash on the inside of the elbows and knees in childhood
  • Can the patient sleep all night or does itching wake up the patient?

Find out what type of moisturizer or over-the-counter products have been applied

Ask about dry skin, which can cause itching and rash

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56
Q

Collecting Subjective Data: HAIR LOSS

A
  • Ask if there is hair thinning or hair shedding and, if so, where? (the most common causes of diffuse hair thinning are male and female pattern baldness)
  • If shedding, does the hair come out at the roots or break along the hair shafts? (Hair shedding at the roots is common in telogen effluvium and alopecia areata. Hair breaks along the shaft suggest damage from hair care or tinea capitis)
  • Ask about hair care practices like frequency of shampooing and use of dyes, chemical relaxers, or heating appliances
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57
Q

Collecting Subjective Data: Hair loss
- frontal hairline regression and thinning on
the posterior vertex

A

Male pattern hair loss

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58
Q

Collecting Subjective Data: Hair loss
- thinning that spreads from the crown down
without hairline regression

A

Female pattern hair loss

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59
Q

Collecting Subjective Data: Hair loss
- temporary hair loss due to the excessive shedding
of resting or telogen hair several months after a person experiences a traumatic event or stress

A

Telogen effluvium

60
Q

Collecting Subjective Data: Hair loss
- an autoimmune disorder that results in unpredictable, patchy hair loss

A

Alopecia areata

61
Q

Collecting Subjective Data: Hair loss
- fungal infection of the scalp that causes itchy,
scaly, bald patches on the head

A

Tinea capitis

62
Q

Collecting Subjective Data: Nail changes
- a superficial infection of the proximal and lateral nail folds adjacent to the nail plate that arises from local trauma due to nail biting, manicuring or frequent immersion in water

A

Paronychia

63
Q

Collecting Subjective Data: Nail changes
- a bulbous swelling of the soft tissue at the nail base, with the loss of the normal angle between the nail and the proximal nail fold. Seen in congenital heart disease, interstitial lung disease
and lung cancer

A

Nail clubbing

64
Q

Collecting Subjective Data: Nail changes
- depression of the central nail with a “Christmas
tree” appearance from small horizontal depressions, resulting from repetitive trauma from
rubbing the index finger over the thumb or vice versa

A

Habit Tic deformity

65
Q

Collecting Subjective Data: Nail changes
- increased pigmentation in the nail matrix,
leading to a streak as the nail grows out

A

Melanonychia

66
Q

Collecting Subjective Data: Nail changes
- painless separation of the whitened opaque nail plate from the pinker translucent nail bed which may be caused bytrauma from excess manicuring,
psoriasis, fungal infection, and allergic reactions to nail cosmetics.

A

Onycholysis

67
Q

Collecting Subjective Data: Nail changes
- a fungal infection of the nails that cause
discoloration, thickening, and separation from the nail bed

A

Onychomycosis

68
Q

Collecting Subjective Data: Nail changes
- nail plate turns white with a ground-glass appearance, a distal band of reddish brown, and
obliteration of the lunula. Seen in liver disease, heart failure, and diabetes.

A

Terry nails

69
Q

Collecting Subjective Data: Nail changes
- transverse depressions of the nail plates,
usually bilateral, resulting from temporary disruption of the proximal nail growth from systemic illness

A

Beau’s lines

70
Q

Collecting Subjective Data: Nail changes
- punctuate depressions of the nail plate caused by
defective layering of the superficial nail plate by the proximal nail matrix. Usually associated with psoriasis

A

Pitting

71
Q

Collecting Objective Data: PREPARING THE CLIENT

A
  • Ask the client to remove all clothing and jewelry and put on an examination gown
  • Ask to remove nail enamel, artificial nails, wigs, toupees, or hairpieces
  • Have the client sit comfortably on the examination table or bled
  • In assessing the skin on the buttocks and dorsal surfaces of the legs, the client may lie on her side or abdomen
  • Ensure privacy and comfortability
  • Sunlight is preferred, but a bright light can be used as well
  • Wear gloves when palpating any lesions
  • Clients from conservative religious groups may require the nurse to be the same sex as the client
72
Q

Collecting Objective Data: EQUIPMENT

A
  • Examination light
  • Penlight
  • Mirror
  • Magnifying glass
  • Centimeter ruler
  • Gloves
  • Wood’s lamp
  • Examination gown or drape
  • Braden Scale for Predicting Pressure
    Sore Risk
  • Pressure Ulcer Scale for Healing (PUSH) to measure pressure ulcer healing
73
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal general skin color.

A

Evenly colored skin tones without unusual prominent discolorations

74
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of general skin color.

A
  • Pallor
  • Cyanosis
  • Jaundice
  • Acanthosis nigricans
75
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of general skin color.
- Seen in arterial insufficiency, decreased blood
supply, and anemia

A

Pallor

76
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of general skin color.
- Roughening and darkening of skin in localized areas especially the posterior neck

A

Acanthosis nigricans

77
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of odors emanating from the skin.

A

Slight or no odor of perspiration depending on activity

78
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of odors emanating from the skin.

A

A strong odor of perspiration or foul odor may indicate disorder of sweat glandsor poor hygiene

79
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of color variations.

A
  • Suntanned areas, freckles, or white patches known as vitiligo; albinism.
  • Dark-skinned clients may have lighter-colored palms, soles, nail beds, and lips
  • Freckle-like or dark streaks of pigmentation are also common in the sclera and nail beds of
    dark-skinned clients
80
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of color variations.

A
  • Rashes
  • Erythema (skin redness and warmth) seen in inflammation, allergic reactions, or trauma
81
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of skin integrity.

A

Skin is intact, and there are no reddened areas

82
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of skin integrity.

A

Skin breakdown is initially noted as reddened area on the skin that may progress to serious and painful pressure ulcers

83
Q

Identify which of the 4 stages of ulcers is being described
- The area looks red and feels warm to the touch. With darker skin, the area may have a blue or purple tint. The person may also complain that it burns, hurts, or itches.

A

Stage I

84
Q

Identify which of the 4 stages of ulcers is being described
- The area looks more damaged and may have an open sore, scrape, or blister. The person complains of significant pain and the skin around the wound may be discolored.

A

Stage II

85
Q

Identify which of the 4 stages of ulcers is being described
- The area has a crater-like appearance due to damage below the skin’s surface.

A

Stage III

86
Q

Identify which of the 4 stages of ulcers is being described
- The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage.

A

Stage IV

87
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of suspected fungus, shine
a Wood’s light on the lesion.

A

Lesion does not fluoresce

88
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of suspected fungus, shine
a Wood’s light on the lesion.

A

Blue-green fluorescence indicates fungal infection

89
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of skin lesions.

Note:
- Note color, shape and size. For very small lesions, use a magnifying glass
- Note its location, distribution, and configuration
- Measure the lesion with a centimetre ruler

A

Skin is smooth, without lesions. Stretch marks, healed scars, freckles, moles, or birthmarks are common findings. Freckles or moles may be scattered over the skin in no particular pattern.

90
Q

PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of skin lesions.

Note:
- Note color, shape and size. For very small lesions, use a magnifying glass
- Note its location, distribution, and configuration
- Measure the lesion with a centimetre ruler

A
  • Primary lesions
  • Secondary lesions
  • Vascular lesions
91
Q

Identify the primary lesions being described
- small flat spot measuring <1cm

A

Macules

92
Q

Identify the primary lesions being described
- larger flat spot measuring >1cm

A

Patches

93
Q

Identify the primary lesions being described
- small raised spot measuring <1cm

A

Papule

94
Q

Identify the primary lesions being described
- larger raised spot measuring >1cm

A

Plaque

95
Q

Identify the primary lesions being described
- raised, fluid-filled, and small lesion measuring <1cm

A

Vesicle

96
Q

Identify the primary lesions being described
- raised, fluid-filled, and large lesion measuring >1cm

A

Bulla

97
Q

Identify the primary lesions being described
- small, palpable collection of neutrophils or
keratin that appears white

A

Pustules

98
Q

Identify the primary lesions being described
- inflamed hair follicle

A

Furuncle

Notes: multiple furuncles together form a carbuncle

99
Q

Identify the primary lesions being described
- larger and deeper than a papule

A

Nodule

100
Q

Identify the primary lesions being described
- encapsulated collections of fluid or semisolid

A

Subcutaneous mass/cyst

101
Q

Identify the primary lesions being described
- area of localized dermal edema that evanesces
within a period of 1-2 days

A

Wheal

102
Q

Identify the primary lesions being described
- small, linear or serpiginous pathways in the
epidermis created by the scabies mite

A

Burrow

103
Q

Identify the Secondary lesions being described
- loss of superficial epidermis that does not
extend to the dermis

A

Erosion

104
Q

Identify the Secondary lesions being described
- skin mark left after healing of wound or
lesion that represents replacement by connective tissue of the injured tissue

A

Scar (Cicatrix)

105
Q

Identify the Secondary lesions being described
- skin loss extending past epidermis with necrotic tissue loss

A

Ulcer

106
Q

Identify the Secondary lesions being described
- linear crack in the skin that may extend to the dermis and may be painful

A

Fissure

107
Q

Identify the Secondary lesions being described
- round red or purple macule that is 1-2mm in size. It is secondary to blood extravasation and associated with bleeding tendencies or emboli to skin

A

Petechia

108
Q

Identify the Secondary lesions being described
- round or irregular macular lesion that is larger than a petechial lesion

A

Ecchymosis

109
Q

Identify the Secondary lesions being described
- a localized collection of blood creating an elevated ecchymosis

A

Hematoma

110
Q

Identify the Secondary lesions being described
- papular and round, red or purple lesion found
on the trunk or extremities. Normal age-related skin alteration

A

Cherry angioma

111
Q

Identify the Secondary lesions being described
- red arteriole lesion with a central body with
radiating branches. Associated with liver disease, pregnancy, and vitamin B deficiency

A

Spider angioma

112
Q

Identify the Secondary lesions being described
- bluish or red lesion with varying shape found on the legs and anterior chest. Associated with
varicosities

A

Telangiectasis (Venous star)

113
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess texture, Normal Findings
- Use the palmar surface of your three middle
fingers to palpate skin texture

A

Skin is smooth and even

114
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess texture, Abnormal Findings
- Use the palmar surface of your three middle
fingers to palpate skin texture

A
  • Rough, flaky, dry skin is seen in hypothyroidism
  • Obese clients often report dry itchy skin
115
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess thickness, Normal Findings

  • If lesions are noted, put gloves on and palpate the lesion between the thumb and index finger for size, mobility, consistency, and tenderness. Observe for drainage or other characteristics
A
  • Skin is normally thin but calluses (rough, thick sections of epidermis) are common on areas of the body that are exposed to constant pressure
  • No lesions palpated
116
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess thickness, Abnormal Findings
- If lesions are noted, put gloves on and palpate the lesion between the thumb and index finger for size, mobility, consistency, and tenderness. Observe for drainage or other characteristics

A
  • Very thin skin may be seen in clients with arterial insufficiency or those on steroid therapy
  • Infected lesions may be tender to palpate. Nonmobile, fixed lesions may be cancer
117
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess moisture, Normal Findings
- Check under skin folds and in
unexposed areas
- Use the dorsal surfaces of the
hands

A

Skin surfaces vary from moist to dry depending on the area assessed. Recent activity or a
warm environment may cause increased moisture

118
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess moisture, Abnormal Findings
- Check under skin folds and in
unexposed areas
- Use the dorsal surfaces of the
hands

A
  • Increased moisture or
    diaphoresis may occur in
    conditions such as fever or
    hypothyroidism
  • Decreased moisture occurs with dehydration or hypothyroidism
  • Clammy skin is typical in shock or hypotension
119
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess Temperature, Normal Findings

A

Skin is normally a warm temperature

120
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess Temperature, Abnormal Findings

A
  • Cold skin may accompany shock or hypotension.
  • Cool skin may accompany arterial disease.
  • Very warm skin may indicate a febrile state or
    hyperthyroidism
121
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess mobility and skin turgor, Normal Findings

-Ask the client to lie down. Using two fingers,
gently pinch the skin over the clavicle.

A

Normally. The skin is mobile, with elasticity and returns to original shape quickly

122
Q

refers to how easily the skin can be pinched.

A

Mobility

123
Q

refers to the skin’s elasticity and how quickly the skin returns to its original shape after being pinched

A

Turgor

124
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess mobility and skin turgor, Abnormal Findings

-Ask the client to lie down. Using two fingers,
gently pinch the skin over the clavicle.

A
  • Decreased mobility is seen with edema.
  • Decreased turgor is seen in dehydration.
125
Q

PHYSICAL ASSESSMENT – SKIN (PALPATION): assess to detect edema, Normal Findings

-Use your thumbs to press down on the skin of the feet or ankles to check for edema (swelling related o accumulation of fluid in the tissue)

A

Skin rebounds and does not remain indented when pressure is released

126
Q

TYPES OF PERIPHERAL EDEMA

A

Non-pitting edema and Pitting edema

127
Q

Identify which type of edema is being described
* Associated with lymphedema
* Caused by abnormal or blocked lymph vessels
* Usually bilateral
* No skin ulceration or pigmentation

A

Non-pitting edema

128
Q

Identify which type of edema is being described
* Associated with chronic venous insufficiency
Pitting documented as:
1+ - slight pitting
2+ - deeper than 1+
3+ - noticeably deep pit; extremely looks larger
4+ - very deep pit; gross edema in extremity
* Usually unilateral
* Skin ulceration and pigmentation may be present

A

Pitting edema

129
Q

PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal general color and condition

A

Natural hair color as opposed to chemically colored hair, varies among clients from pale
blond to black to gray or white

130
Q

PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Abnormal general color and condition

A
  • Nutritional deficiencies may cause patchy gray hair in some clients.
  • Severe malnutrition may cause a copper-red hair color
131
Q

PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal Findings, At 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions.
-Wear gloves if lesions are suspected
or if hygiene is poor

A

Scalp is clean and dry. Sparse dandruff may be visible. Hair is smooth and firm, somewhat
ecstatic

132
Q

PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Abnormal Findings, At 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions.
-Wear gloves if lesions are suspected
or if hygiene is poor

A
  • Excessive scaliness may indicate dermatitis.
  • Raised lesions may indicate infections or tumor growth.
  • Dull, dry hair may be seen with hypothyroidism and malnutrition.
  • Poor hygiene may indicate a need for client teaching or assistance with activities of daily living
  • Pustules with hair loss in patches are seen in tinea capitis, a contagious fungal disease
  • Infections of the hair follicle appear as pustules surrounded by erythema
133
Q

PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal Findings, amount and distribution of scalp, body, axillae, and pubic hair.

  • Look for unusual growth elsewhere in the body
A
  • Varying amounts of terminal hair cover the scalp, axillary, body, and pubic areas according to normal gender distribution.
  • Fine vellus hair covers the entire body except for the soles, palms, lips, and nipples. Normal male pattern balding is symmetric
134
Q

PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Abnormal Findings, amount and distribution of scalp, body, axillae, and pubic hair.

  • Look for unusual growth elsewhere in the body
A
  • Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity,
    hepatic or renal failure. It may also result from
    chemotherapy or radiation therapy.
  • Patchy hair loss may result from infections of the scalp, discoid or systemic lupus erythematosus, and some types of chemotherapy.
  • Hirsutism (facial hair on females) is a characteristic of Cushing’s disease and results from an imbalance of adrenal hormones or it may be a side effect of steroids
135
Q

PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal Findings, nail grooming and cleanliness

A

Nails are clean and manicured

136
Q

PHYSICAL ASSESSMENT – NAILS (INSPECTION): Abnormal Findings, nail grooming and cleanliness

A

Dirty, broken, or jagged fingernails may be seen with poor hygiene. They may also result from the client’s hobby or occupation

137
Q

PHYSICAL ASSESSMENT – NAILS (INSPECTION): Normal Findings, nail color and markings

A

Pink tones should be seen. Longitudinal ridging is normal

138
Q

PHYSICAL ASSESSMENT – NAILS (INSPECTION): Abnormal Findings, nail color and markings

A
  • Pale or cyanotic nails may indicate hypoxia or anemia.
  • Splinter hemorrhages may be caused by trauma.
  • Beau’s lines occur after acute illness and eventually grow out.
  • Yellow discoloration may be seen in fungal infections or psoriasis.
  • Nail pitting is also common in
    psoriasis
139
Q

PHYSICAL ASSESSMENT – NAILS (INSPECTION): Normal Findings, shape of nails

A

There is normally a 160-degree angle between the nail base and the skin

140
Q

PHYSICAL ASSESSMENT – NAILS (INSPECTION): Abnormal Findings, shape of nails

A

Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia

141
Q

PHYSICAL ASSESSMENT – NAILS (PALPATION): Normal Findings, assess texture

A

Nails are hard and basically immobile

142
Q

PHYSICAL ASSESSMENT – NAILS (PALPATION): Abnormal Findings, assess texture

A

Thickened nails (especially toenails) may be caused by decreased circulation, and is
also seen in onychomycosis.

143
Q

PHYSICAL ASSESSMENT – NAILS (PALPATION): Normal Findings, assess texture and consistency, noting whether nail plate is attached to nail bed

A

Nails are smooth and firm; nails plate should be firmly attached to nail bed

144
Q

PHYSICAL ASSESSMENT – NAILS (PALPATION): Abnormal Findings, assess texture and consistency, noting whether nail plate is attached to nail bed

A

Paronychia (inflammation) indicates local infection. Detachment of nail plate from
nail bed (onycholysis) is seen in infections or trauma.

145
Q

PHYSICAL ASSESSMENT – NAILS (PALPATION): Normal Findings, Test capillary refill
- pressing the nail tip briefly and watching for color change

A

Pink tone returns immediately to blanched nail beds when pressure is released

146
Q

PHYSICAL ASSESSMENT – NAILS (PALPATION): Abnormal Findings, Test capillary refill
- pressing the nail tip briefly and watching for color change

A

There is slow (greater than 2 seconds) capillary nail bed refill (return of pink tone) with respiratory or cardiovascular diseases that cause hypoxia.

Health Assessment Lecture (17 decks)

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