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HA LEC [Midterms] > Assessment of Skin, hair, and nails > Flashcards

Assessment of Skin, hair, and nails Flashcards

1
Q

What is the largest organ of the body?

A

Skin

Note:

  • It is our physical barrier that protects us from the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration.
  • It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin synthesis.
  • Provides identity to a person’s appearance, like fingerprints and thumbmarks.
  • The skin is thicker on the palms of the hands and soles of the feet and is continuous on the mucus membranes at the orifices of the body.
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2
Q

The skin is composed of 3 Layers. What are these?

A
  • Epidermis (Epidermal)
  • Dermis (Dermal)
  • Hypodermis (Subcutaneous Tissue)
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3
Q

This is the outermost layer of the skin that is consist of dead, keratinized cells which renders the skin to be waterproof.

A

Epidermis (Epidermal)

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4
Q

This is present on the epidermis hair, nails, dental enamel, and horny tissue composed of keratin.

A

Keratin

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5
Q

Epidermal layer replaced every how many weeks?

A

3-4 weeks

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6
Q

WHAT IS THIS?

  • It undergoes cell division and contains melanin together with capillary blood flow, chromophores.
A

Stratum Spinosum and Basale

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7
Q

WHAT IS THIS?

  • Brown pigment
  • Major Determinant of the Skin
A

Melanin

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8
Q

This is the Inner layer of the skin. It contains elastic fibers, nerve endings, and lymph vessels. It is also the origin of sweat glands and hair follicle.

A

Dermis

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9
Q

Dermis is visible in the hands and feet, and it creates the unique pattern of friction ridges commonly known as what?

A

Fingerprints

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10
Q

No. of fingerprints?

A

Infinite

Note:

  • NO 2 PEOPLE HAVE THE SAME FINGERPRINTS
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11
Q

This is found in the dermis layer of the skin. It is attached to hair follicle and is present over most of the body.

A

Sebaceous glands

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12
Q

The sebaceous glands secretes oil which is called __________.

This waterproofs the hair and skin.

A

Cebum

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13
Q

What are the two types of sweat glands in the skin, both located in the dermis but with different functions?

A

Eccrin and Apocrine

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14
Q

WHAT IS THIS?

  • Found all over the body (entire skin), especially on the palms, soles, and forehead.
  • Produce a clear, watery sweat primarily for thermoregulation (cooling the body).
  • Open directly onto the skin surface.
  • Active from birth.
A

Eccrine glands

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15
Q

WHAT IS THIS?

  • Found in hairy areas like the armpits, groin, and around the nipples.
  • Secrete a thicker, milky fluid containing proteins and lipids.
  • Open into hair follicles.
  • Become active during puberty and are linked to body odor when bacteria break down the sweat.
A

Apocrine Glands

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16
Q

WHAT IS THIS?

  • This is a combination of sweat and skin bacteria.
A

Body Odor

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17
Q

Apocrine is link to what?

A

Menstrual cycle

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18
Q

This is the loose connective tissue that stores fat as an energy reserve, provides insulation to conserve internal body parts, and is a pathway for the nutrients and removal of waste products to and from the skin.

A

Subcutaneous tissue

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19
Q

FAMILIARIZE ONLY!

“What are the Functions of the skin?”

A
  • Protective barrier against invasion from environmental hazards & pathogens. (1st line of defense)
  • Protection for underlying organs
  • Temperature regulations / heat control / Vit D synthesis
  • Sensory signals
  • Organ of excretion for substances such as water, salts & nitrogenous wastes
  • Indicator of nonverbal language & emotions via blushing & facial expression
  • Purpose of identification via fingerprints & birthmarks
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20
Q

Give 4 Functions of the Skin

(Notes ni ma’am sa slide)

A
  • Protection from microorganisms
  • Protection from trauma
  • Protection from UVR (Ultraviolet rays)
  • Protection from dehydration
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21
Q

WHAT IS THIS?

  • This is consist of keratinized layer found over much of the body, except for lips, nipples, soles of feet, palms of hand, labia minora, and penis.
A

Hair

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22
Q

FAMILIARIZE ONLY!

“What are the Functions of the Hair?”

A
  • Provides warmth, protection and sensation to the underlying systems
  • Vellus hair enhances tactile sensation, thermoregulation
  • Hair on the head protects the scalp
  • Other hair (filter dust & other airborne debris)
  • In other countries, status symbol of beauty and wealth
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23
Q

What are the 2 Types of Hair found on the human body?

A
  • Vellus Hair (Peach fuzz)
  • Terminal Hair

Note:

OTHER HAIRS are

  • Burnik - buhok sa pwet
  • Tutsang - buhok sa ilong
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24
Q

What type of hair is this?

  • Fine, soft, and unpigmented (light-colored).
  • Covers most of the body except for the lips, palms, and soles.
  • Provides slight insulation and protection.
A

Vellus Hair (Peach Fuzz)

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25
Q

What type of hair is this?

  • Thicker, coarser, and darker.
  • Found on the scalp, eyebrows, eyelashes, and, after puberty, in areas like the armpits and pubic region.
  • Influenced by hormones, especially androgens.
A

Terminal Hair

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26
Q

Hair color is determined by the amount and type of pigment present in the hair shaft.

What are the 2 main pigments?

A

Melanin and Pheomelanin

Note:

  • Aging leads to a decrease in melanin production, resulting in gray or white hair.
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27
Q

Nails are _____________?

A

keratinized

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28
Q

Nails appear ___________ due to the presence of blood vessels beneath the nail bed.

A

pink-tinged

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29
Q

WHAT IS THIS?

  • Provide protection to the distal surface of the digits and can be used for self-protection.
  • In many cultures, length in both men & women is a qualifier of social and economic status.
A

Nails

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30
Q

WHAT IS THIS?

  • Crescent shape at the base of the nail, visible aspect of the nail matrix.
A

Lunula

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31
Q

MEMORIZE!!!

“Parts of the Nail”

A

OUTER PARTS:

  • Edge of nail
  • Nail plate
  • Lunula
  • Cuticle

INNER PARTS:

  • Nail bed
  • Root of Nail
  • Nail matrix
  • Hyponychium
  • Finger bone
  • Epidermis
  • Dermis
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32
Q

In Collecting the Subjective Data, what are the 4 Informations we need to get?

A
  • History of Present Concern
  • Personal Health History
  • Family History
  • Lifestyle and Health Practices
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33
Q

FAMILIARIZE ONLY!

“Scope of Present Health Concern in Skin and Hair & Nails”

A

SKIN

  • Skin problems, birthmarks or moles, ABCDEs of skin cancer, ability to feel pain, itching, tingling or numbness, any medications, body odor, excessive perspiration.

HAIR & NAILS

  • Hair loss or change in the condition, appearance of nails
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34
Q

What are the 5 Types of Tattoos?

A
  • Traumatic Tattoo
  • Amateur Tattoo
  • Professional Tattoo
  • Medical Tattoo
  • Cosmetic Tattoo
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35
Q

What type of tattoo is this?

  • Caused by debris embedded in the skin.
  • This occurs when particles (like dirt, ash, or gunpowder) enter the skin due to an accident or injury, leaving a permanent mark.

Example:

  • Motorcycle accident
A

Traumatic Tattoo

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36
Q

What type of tattoo is this?

  • Uses India ink.
  • Created by non-professionals using improvised tools. These tattoos often appear uneven, faded, or blurry due to shallow ink penetration.
A

Amateur Tattoo

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37
Q

What type of tattoo is this?

  • Made by trained tattoo artists using sterile equipment and high-quality ink. These tattoos are precise, detailed, and deeply embedded in the dermis, making them long-lasting.
A

Professional Tattoo

Note:

  • In assessment, put “Presence of a professional tattoo” and then indicate the part of the body (Left or right arm).
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38
Q

What type of tattoo is this?

Used in medical procedures for various purposes, such as:

  • Marking radiation treatment sites in cancer therapy.
  • Restoring nipple-areola pigmentation after breast surgery.
  • Camouflaging scars or skin conditions like vitiligo.
A

Medical Tattoo

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39
Q

What type of tattoo is this?

Also called micropigmentation, this involves tattooing pigments to enhance facial features, such as:

  • Eyebrows (Microblading)
  • Eyeliner
  • Lip tinting
A

Cosmetic Tattoo

Note:

  • In assessment, put “Cosmetic Tattoo (eyeliner)”
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40
Q

Tattooing is related to what infection?

A

Hepatitis C infection

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41
Q

FAMILIARIZE ONLY!!!

“How to Examine Own Skin?”

A
  • Hair - Use Mirror, Blower for scalp
  • Nails - Check hands, elbows, arms, underarms
  • Neck - Check, women check under breasts for any rashes or discoloration
  • Legs - Check the legs, soles of the feet, heels, and nails
  • Genitalia - use mirror
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42
Q

FAMILIARIZE ONLY!

“Specific Health History Questions Regarding the Skin, Hair, and Nails”

A

SKIN HAIR HABITS:

  • Do you use lotion, perfumes, cologne, cosmetics, soap, oils, shaving cream, after shave lotion, electric or standard razor?
  • What type of home remedies do you use for skin lesions & rashes?
  • How often do you bathe or shower?
  • Do you use a tanning bed or salon?
  • What type of sun protection do you use?
  • Have your ever had a reaction to jewelry that you wore?
  • Do you wear hats, visors, gloves, long sleeves or pants, sunscreen when in the sun?
  • How much time do you spend in the sun?

HAIR CARE HABITS:

  • Do you use shampoo, conditioner, hair spray, setting products?
  • Do you color, dye, bleach, frost, or use relaxants on your hair?
  • What products do you use?
  • Do you wear a wig or hairpiece?
  • Do you have graying hair or hair loss?
  • Do you use hair dryer, heated curlers, or curling iron?
  • Do you tightly braid your hair?

NAIL CARE HABITS:

  • Do you get manicure or pedicures?
  • What type of nail care do you practice (trimming, clipping, use of polish, nail tips, acrylics)?
  • Do you bite your nails?
  • Do you suffer from nail splitting or discoloration?
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43
Q

FAMILIARIZE ONLY!

“General Approach to Skin, Hair, and Nails Assessment”

A
  1. Ensure that all rooms are well-lit. Daylight is the best source of light, especially when determining skin color. However, if daylight is unavailable, overhead fluorescent lights should be added.
  2. Use a handled magnifying glass to aid in inspection when simple visual inspection is not adequate.
  3. Explain to the patient each step of the assessment prior to initiating the assessment.
  4. Ensure patient privacy by providing drapes.
  5. Ensure the comfort of the patient by keeping the room at an appropriate temperature.
  6. Warm hands by washing them in warm water prior to the assessment.
  7. Gather equipment on a table prior to initiating the assessment.
  8. Ask the patient to undress completely & put on a patient gown, leaving the back untied.
  9. Perform assessment in a cephalocaudal fashion (head-to-toe).
  10. For episodic illness, the skin examination is incorporated into the original physical exam.
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44
Q

WHAT IS THIS?

  • These are injuries to the skin and underlying tissues caused by prolonged pressure, friction, or shear. They often develop in people who are bedridden, use wheelchairs, or have limited mobility.
A

Pressure ulcers (bedsores)

Note:

  • Cause — unrelieved pressure, friction and shear can contribute to and worsen the condition.
  • Prevalence vary in bed type & clinical area (critical care, long term facility, prolonged bedrest)

Stages of Pressure Ulcers:

  • Stage 1 – Red, non-blanching skin that is intact but painful or warm.
  • Stage 2 – Partial-thickness skin loss, may appear as an open sore or blister.
  • Stage 3 – Full-thickness skin loss, exposing fat layers with a deep wound.
  • Stage 4 – Deep tissue damage, exposing muscles, tendons, or even bone.
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45
Q

FAMILIARIZE ONLY!!

“EQUIPMENTS IN ASSESSING THE SKIN, HAIR, and NAILS”

A
  • Magnifying glass
  • Good source of natural light or examination light
  • Penlight with pupil diameter
  • Clean gloves
  • Microscope slide
  • Small centimeter ruler
  • Gown
  • Braden Scale — Pressure (Risk Assessment)
  • Pressure Ulcer Scale for Healing (PUSH)

For special techniques:

  • Wood’s Lamp
  • # 15 scalpel blade
  • Microscope slide w/ cover slips
  • Mineral oil
  • Microscope
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46
Q

WHAT IS THIS?

  • It is a widely used assessment tool to determine a patient’s risk of developing pressure ulcers (bedsores). It evaluates six risk factors, assigning a score to each, with a lower total score indicating a higher risk.
A

Braden Scale

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47
Q

WHAT IS THIS?

  • It is used to monitor the healing progress of pressure ulcers over time. It was developed by the National Pressure Injury Advisory Panel (NPIAP) to help healthcare providers track improvement or worsening of ulcers.
A

Pressure Ulcer Scale for Healing (PUSH)

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48
Q

WHAT IS THIS?

  • It is a UV (ultraviolet) light used in dermatology to detect skin infections, pigment changes, and other skin conditions. It emits long-wave UVA light (365 nm) and helps identify abnormalities that are not visible under normal light.
A

Wood’s Lamp

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49
Q

WHAT IS THIS?

  • It is a chronic skin condition that causes loss of pigmentation, leading to white patches on the skin. It occurs when melanocytes (pigment-producing cells) are destroyed, resulting in a lack of melanin.
A

Vitiligo

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50
Q

When doing _________________, you need to observe for the ff:

  • Color
  • Bleeding
  • Ecchymosis (Pasa)
  • Vascularity (Ugat-ugat)
  • Lesions (scratches)
  • Moisture (wet or dry)
  • Temperature
  • Texture
  • Turgor (elasticity)
  • Edema (swelling)
A

Skin Inspection

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51
Q

What is the ideal position when assessing the patient’s skin, hair, and nails?

A

Supine position

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52
Q

FAMILIARIZE ONLY!

“SKIN INSPECTION”

A

Position:

  • Supine position

Patient:

  • Wear gown / provide privacy

Done with gloves

Areas to assess:

  • Skin of face, eyelids, nose, lips & mucous membrane
  • Neck, behind the ears, arms, chest, breasts, axilla, abdomen, lower extremities, feet, toes, genitalia

Color:

NORMAL

  • Whitish pink or brown
  • Increase pigmentation
  • Dark skinned person (discoloration of gums & gingiva)
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53
Q

People with fair or light skin have less or decreased melanin, which provides some protection against UV radiation. This makes them more prone to _______________.

A

skin cancer

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54
Q

___________ skin has high melanin.

A

Darker

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55
Q

This is a pigment responsible for the yellowish tint in some skin tones.

56
Q

__________ tend to have paler skin due to reduced melanin production and decreased blood flow (dermal vascularity).

A

Older Adults

57
Q

WHAT IS THIS?

  • __________ means a noticeable loss of normal skin color, making the skin appear pale, ashen, or grayish, especially in individuals with darker skin tones.
  • Pallid to ashen without underlying pink.
A

Pallor (Loss of color)

58
Q

WHAT IS THIS?

  • It occurs due to low oxygen levels in the blood, causing the skin to turn bluish.
  • It is most noticeable in areas with thin skin, such as the lips (perioral), nail beds, and conjunctiva.
A

Cyanosis (Bluish Discoloration)

59
Q

What are the 2 Types of Cyanosis?

A
  • Central cyanosis
  • Peripheral cyanosis
60
Q

What type of cyanosis is this?

  • Seen in the mucous membranes (oral mucosa, lips, tongue) and suggests a serious cardiopulmonary problem (e.g., lung disease, heart failure).
A

Central Cyanosis

61
Q

What type of cyanosis is this?

  • Affects nail beds, hands, feet, and extremities due to poor circulation or vasoconstriction (e.g., cold exposure, Raynaud’s disease).
A

Peripheral Cyanosis

NOTE:

  • To differentiate: Always check the oral mucosa—if it’s blue, the cyanosis is central and could indicate a serious condition.
62
Q

WHAT IS THIS?

  • This is skin redness caused by increased blood flow to the capillaries, usually due to inflammation, infection, fever, or sunburn.
A

Erythema

Note:

  • It is easier to notice in lighter skin, but in darker skin tones, redness may not be visible. Instead, assess skin temperature by touching the affected area (it will feel warmer than surrounding skin).
63
Q

WHAT IS THIS?

  • It refers to the skin’s ability to return to its normal shape after being pinched.
A

Turgor

NOTE:

It helps assess hydration status:

  • Normal: Skin snaps back quickly.
  • Decreased turgor (tenting): Skin stays pinched and returns slowly, indicating dehydration or aging (loss of collagen and elasticity in older adults).
  • Below the clavicular bone.
64
Q

WHAT IS THIS?

  • The skin, sclera (whites of the eyes), and mucous membranes turn yellowish.
65
Q

WHAT IS THIS?

  • Generalized loss of pigmentation due to a genetic absence of melanin in the skin, hair, and eyes.
A

Albinism

Note:

  • We don’t expose these people to sunlight because they are prone to dehydration.
66
Q

WHAT IS THIS?

  • ___ is a chronic autoimmune disease where the body’s immune system attacks its own tissues, causing widespread inflammation and damage to various organs, including the skin, joints, kidneys, heart, and lungs.
  • A red, flat or raised rash that spreads across the cheeks and nose, resembling a butterfly shape.
A

Systemic Lupus Erythematosus (SLE)

67
Q

WHAT IS THIS?

  • Red central body with radiating blood vessels (like a spider’s legs).
A

Spider Angioma

68
Q

WHAT IS THIS?

  • Bluish or purplish web-like veins (dilated veins close to the skin).
A

Venous stars

69
Q

WHAT IS THIS?

  • Small, bright red papules (raised dots).
A

Cherry angioma

70
Q

WHAT IS THIS?

This is a velvety darkening of the skin, often in body folds and creases such as:

  • Neck
  • Groin
  • Axilla (armpits)

It is associated with insulin resistance, obesity, diabetes, or hormonal disorders.

A

Acanthosis Nigricans

71
Q

WHAT IS THIS?

  • When assessing skin color variations, also note any ___________.
A

odors

NOTE:
A strong, foul smell may indicate a disorder of the sweat glands, such as:

  • Bacterial overgrowth
  • Poor hygiene
  • Skin infections
72
Q

FAMILIARIZE ONLY!

“Skin Lesion Assessment”

When assessing lesions, observe the symmetry, borders, shape, color, diameter, and changes over time. This helps determine whether a lesion is benign or potentially malignant.

A
  1. Distribution of Lesions
  • Diffuse – Scattered across the body with no specific pattern (e.g., viral rashes).
  • Localized – Restricted to one specific area or sun-exposed areas (e.g., sunburn, allergic reactions).
  1. Pattern and Arrangement of Lesions
  • Discrete – Separate, individual lesions that do not merge (e.g., acne, insect bites).
  • Grouped – Clusters of lesions appearing together (e.g., herpes simplex, insect bites).
  • Confluent – Merged or blending together, making it difficult to distinguish individual lesions (e.g., measles, urticaria).
  • Linear – Lesions arranged in a straight line (e.g., poison ivy rash, scratches).
  • Annular & Arciform – Circular or arc-shaped lesions (e.g., ringworm for annular, erythema multiforme for arciform).
  • Zosteriform – Lesions follow a nerve pathway in a band-like pattern, common in herpes zoster (shingles).
  1. Assessing Small Lesions
  • Use a magnifying glass to better examine small lesions for texture, shape, and color changes.
  • Pay attention to location, distribution, and configuration to help determine the underlying cause.
  1. Fungal Infections & Wood’s Light Exam
  • Wood’s light (UV light filtered through a special glass) is used to detect certain fungal infections.
  • Findings under Wood’s Light:

= > No fluorescence → Lesion is not fungal.

= > Blue-green fluorescence → Suggests a fungal infection, like tinea (ringworm).

73
Q

FAMILIARIZE ONLY!

“Classification of lesions based on their location, arrangement, elevation, color, and exudates”

A

Lesion Classification:

  1. Non-Palpable Lesions
  • These are flat and cannot be felt when touching the skin.
  • Example: Macule (e.g., freckles, flat moles).
  1. Palpable Lesions
  • These can be felt and raised above the skin surface.

Examples:

  • Papule – A small, solid, raised lesion (e.g., warts, moles).
  • Nodule – A deeper, firmer mass extending into the dermis (e.g., lipoma).
  • Wheal – A raised, irregular-shaped area due to fluid accumulation (e.g., hives).
  1. Fluid-Filled Lesions
  • These contain liquid inside.

Examples:

  • Vesicle – A small, fluid-filled blister (e.g., chickenpox, herpes).
  • Pustule – A pus-filled lesion (e.g., acne, impetigo).
  1. Lesions Above the Skin Surface
  • These are elevated due to excess skin formation.

Examples:

  • Scales – Flakes of dead skin (e.g., psoriasis, dandruff).
  • Crusts – Dried exudates (e.g., scab from a healing wound).
  1. Lesions Below the Skin Surface
  • These involve loss of skin tissue or deep structural changes.

Examples:

  • Erosion – Superficial loss of epidermis (e.g., after a blister pops).
  • Ulcer – Deep loss of skin tissue with possible scarring (e.g., pressure ulcers).
  • Keloid – Overgrowth of scar tissue beyond the original wound.
  • Fissure – A deep crack or split in the skin (e.g., cracked heels, angular cheilitis).
  • Scar – Fibrous tissue replacing normal skin after healing.
  • Excoriation – Superficial skin loss due to scratching (e.g., insect bite marks).
74
Q

WHAT IS THIS?

  • It is a type of cancer that begins in epithelial cells, which line the skin and internal organs. It is one of the most common forms of cancer and can occur in different parts of the body, including the skin, lungs, breasts, prostate, and digestive tract.
75
Q

Carcinoma can be ___________ or ____________.

A

Primary or Secondary

76
Q

This is the Carcinoma that originates in the skin itself.

A

Primary Carcinoma

77
Q

This is the Carcinoma that spreads (metastasizes) from another part of the body to the skin.

A

Secondary carcinoma

78
Q

What are the 3 Classification of Skin Cancer?

A
  • Squamous Cell Carcinoma (SCC)
  • Basal Cell Carcinoma (BCC)
  • Malignant Melanoma
79
Q

Under the classification of Skin Cancer, what is this?

  • Develops from squamous cells in the epidermis.
  • Often appears as a scaly, red patch, open sore, or thickened skin.
  • Can metastasize if untreated.
  • Commonly caused by prolonged sun exposure.
A

Squamous Cell Carcinoma (SCC)

80
Q

Under the classification of Skin Cancer, what is this?

  • Most common but least aggressive type.
  • Appears as a pearly or waxy bump, sore that doesn’t heal, or reddish patch.
  • Grows slowly and rarely spreads.
  • Linked to UV radiation exposure.
A

Basal Cell Carcinoma (BCC)

81
Q

Under the classification of Skin Cancer, what is this?

  • Most dangerous form of skin cancer.
  • Arises from melanocytes (pigment-producing cells).
  • Can spread quickly to other organs.
  • Often starts as a new mole or changes in an existing mole.
A

Malignant Melanoma

82
Q

What is the ABCDEs of Skin Cancer (Warning Signs of Melanoma)?

A
  • A – Asymmetry: One half of the mole is different from the other.
  • B – Border: Irregular, scalloped, or poorly defined edges.
  • C – Color: Varied shades of brown, black, red, blue, or white.
  • D – Diameter: Larger than 6mm (about the size of a pencil eraser).
  • E – Evolving: Any change in size, shape, color, or symptoms (bleeding, itching, etc.).

NOTE:

  • If caught & treated early, before it advances & spreads to other parts of your body, melanoma can almost always be cured.
83
Q

In Skin Assessment, the Texture is assess by using the Palmar surface of __________________?

A

Three middle fingers

84
Q

SKIN ASSESSMENT

  • Rough, flaky texture skin can indicate what?
A

hypothyroidism

85
Q

SKIN ASSESSMENT

  • Dirty and itchy skin is often observed in ________ individuals due to poor hygiene or friction.
86
Q

SKIN ASSESSMENT

  • The ___________ and __________ of the skin is common to patient with constant pressure and taking steroids.
A

thickness and thinness

87
Q

SKIN ASSESSMENT

  • Cold, clammy skin indicates possible _______________?
A

shock or hypotension

88
Q

SKIN ASSESSMENT

  • Cool skin may indicate ___________ (poor circulation).
A

arterial disease

89
Q

SKIN ASSESSMENT

  • ______________: Assesses hydration and skin elasticity
  • Method: As the patient to lie down, pinch the skin over the clavicle using two fingers.
  • Normal: Skin is mobile, elastic, and quickly returns to its original shape.
A

Turgor

Note:

  • Recoil is immediate.
90
Q

SKIN ASSESSMENT - Turgor

  • If the Recoil time is less than 2 secs, it means ______________.
A

Moderate Dehydration (DHN)

91
Q

SKIN ASSESSMENT - Turgor

  • If the Recoil time is more than 2 secs, it means ______________.
A

Severe Dehydration (DHN)

92
Q

SKIN ASSESSMENT - Turgor

  • If the Recoil time is more than 3 secs, it means ______________.
93
Q

FAMILIARIZE ONLY!

“PALPATION OF THE SKIN”

A
  1. Moisture - Dry w/ perspiration
  2. Temperature - Warm & equal bilateral
  3. Tenderness - Surface is non tender
  4. Texture - Smooth, even, firm
  5. Turgor - Should return to its original contour rapidly
  6. Thickness - Thin but calluses (constant pressure.
  7. Edema
94
Q

4 Point Scale (Edema)

A
  • +0 - No pitting
  • +1 - 0’’ - 1/4’’ MILD
  • +2 - 1/4’’ - 1/2’’ MODERATE
  • +3 - 1/2’’ - 1’’ SIGNIFICANT
  • +4 - greater than 1’’ PITTING
95
Q

In skin assessment, a ___________ refers to an area of the body where bones are close to the skin’s surface, making it more prone to pressure ulcers (bedsores) due to prolonged pressure, friction, or shear forces.

A

Pressure points

96
Q

In Supine Position, what are the (4) pressure points?

A
  • Occiput
  • Scalpula
  • Sacrum
  • Heels
97
Q

In Lateral Position, What are the (7) Pressure Points?

A
  1. Ear
  2. Acromion process
  3. Elbow
  4. Trochanter
  5. Medial and lateral condyle
  6. Medial and lateral malleolus
  7. Heels
98
Q

In Prone Position, what are the (7) Pressure Points?

A
  1. Elbow
  2. Ear, cheek, nose
  3. Breasts (female)
  4. Genitalia (male)
  5. Iliac crest
  6. Patella
  7. Toes
99
Q

What is the scale used to predict pressure sore risk?

A

Braden Scale

100
Q

What is the tool used to document the degree of skin breakdown?

A

PUSH tool or Pressure Ulcer Scale for Healing

101
Q

What should a nurse do to prevent bedsores?

A

Turning should be done every 2 hours

102
Q

IN NAIL ASSESSMENT, what is this?

  • Indicate poor hygiene; may reflect the client’s work or hobbies (e.g., mechanics, gardeners).
A

Dirty nails

103
Q

IN NAIL ASSESSMENT, what is this?

  • Suggest hypoxia (lack of oxygen) or anemia.
A

Pale or cyanotic nails

104
Q

IN NAIL ASSESSMENT, what is this?

  • Tiny red or brown streaks under the nail; may be due to trauma or endocarditis.
A

Splinter hemorrhage

105
Q

IN NAIL ASSESSMENT, what is this?

  • Horizontal depressions across the nail; occur after acute illness, malnutrition, or chemotherapy.
A

Beau’s lines

106
Q

IN NAIL ASSESSMENT, what is this?

  • Associated with fungal infection (onychomycosis) or psoriasis.
A

Yellow discoloration

107
Q

IN NAIL ASSESSMENT, what is this?

  • May indicate poor circulation or fungal infection (onychomycosis).
A

Thickened nails

108
Q

What is the normal color of our nails?

A

Pink & brown

109
Q

In testing the capillary refill, what is the normal time”?

A

1-2 secs or less than 2 secs”

110
Q

In capillary refill time, how many secs is considered abnormal?

A

2-3 secs and above

Note:

  • When the capillary refill time is abnormal, then it indicates CVD (Cardiovascular Disease)
111
Q

IN NAIL ASSESSMENT, under shape & configuration.

  • The nails should be smooth & rounded or flat
  • What should be normal angle?
112
Q

IN NAIL ABNORMALITIES, what is this?

  • Angle between the nail and nail bed is 180° or more with a spongy sensation when pressed.
A

Clubbing of Nails

Note:

  • People who has this actually experienced prolonged difficulty of breathing. So they often have upper or lower respiratory diseases. This is common to smokers
113
Q

IN NAIL ABNORMALITIES, what is this?

  • Thin, concave (spoon-shaped) nails that may hold a drop of water.

Cause: Iron deficiency anemia.

A

Spoon nails

114
Q

IN NAIL ABNORMALITIES, what is this?

  • A fungal infection of the nails, commonly affecting toenails more than fingernails.
A

Onychomycosis

115
Q

IN NAIL ABNORMALITIES, what is this?

  • Inflammation of the skin around the nail (nail folds).
A

Paronychia

116
Q

IN NAIL ABNORMALITIES, what is this?

  • Separation or detachment of the nail from the nail bed.
A

Onycholysis

117
Q

IN INSPECTION OF ______:

We inspect the ff:

  • Scalp hair
  • Eyebrows
  • Eyelashes
  • Body hair
118
Q

At how many inch intervals do we inspect the scalp cleanliness, parasites, and lesions?

A

1 inch intervals

119
Q

IN INSPECTION OF HAIR, what is this?

Excessive scaliness may indicate ________?

A

Dermatitis

120
Q

IN INSPECTION OF HAIR, what is this?

  • Lesions could suggest a _______ or ________.
A

Tumor or infection

121
Q

IN INSPECTION OF HAIR, what is this?

  • Dull or dry hair is common in _________ and ___________.
A

Hypothyroidism and Malnutrition

122
Q

IN HAIR CONDITIONS, what is this?

  • This is also called as scalp ringworm.
  • Fungal infection causing round, scaly patches and hair breakage.
A

Tinea capitis

123
Q

IN HAIR ABNORMALITIES

The ff indicates what?

  • Infections
  • Nutritional deficiencies
  • Hormonal imbalances (thyroid disorders)
  • Liver disease, drug toxicity, hepatic or renal failure
A

Excessive Generalized Hair Loss

124
Q

IN HAIR ABNORMALITIES

The _______ can be seen in:

  • Chemotherapy
  • Infections (e.g., tinea capitis, alopecia areata)
A

Patch hair loss

125
Q

IN HAIR CONDITIONS, what is this?

  • This refers to hair loss or absence of hair in areas where it is normally present. It can be temporary or permanent, depending on the cause.
126
Q

IN HAIR CONDITIONS, what is this?

  • An autoimmune condition, body’s immune system attacks the health cells including the hair follicle causing patch hair loss on the scalp or body.
A

Alopecia Areata

127
Q

IN HAIR ABNORMALITIES, what is this?

  • It is the excessive growth of coarse, dark hair in areas where women typically have minimal hair (face, chest, back).
A

Hirsutism

Note:

  • Characterized of Cushing Disease and Polycystic ovary syndrome (PCOS) and results in imbalance of adrenal hormones or side effect of steroids.

Cushing disease is the overproduction of ACTH

128
Q

WHAT IS THIS?

  • Ovaries produce excess androgens (male hormones).
  • Leads to irregular periods, acne, and fluid-filled sacs (cysts) in the ovaries.
A

Polycystic Ovary Syndrome (PCOS)

129
Q

WHAT IS THIS?

  • A male sex hormone present in both men and women, but in small amounts in females.
130
Q

WHAT IS THIS?

  • Multiple cysts (fluid-filled sac) in the ovaries.
A

Polycystic

Note:

  • “Poly” (many) + “Cystic” (fluid-filled sacs)
131
Q

WHAT IS THIS?

  • It is the inflammation or infection of hair follicles, leading to small red bumps, pustules, or irritation on the skin.
A

Folliculitis

132
Q

FAMILIARIZE ONLY!

“SKIN, HAIR, AND NAILS”

A

Inspection of the Skin

  • Color
  • Bleeding, ecchymosis, and vascularity
  • Lesions

Palpation of the Skin

  • Moisture
  • Temperature
  • Tenderness
  • Texture
  • Turgor
  • Edema

Inspection of the Hair

  • Color
  • Distribution
  • Lesions

Palpation of the Hair

  • Texture

Inspection of the Nails

  • Color
  • Shape & Configuration

Palpation of the Nails

  • Texture
133
Q

WHAT IS THIS?

  • Infestation of hairy parts of the body or clothing with eggs, larvae, or adult lice. Feed with human blood that causes itching sensation.
A

Pediculosis

134
Q

What are the 3 Types of Pediculosis?

A
  • Head lice
  • Crab lice
  • Body lice
135
Q

What is the treatment for pediculosis?

A

Permethrin lotion or shampoo

136
Q

IN SKIN ABNORMALITIES

  • A 63 year old woman presents with symmetrical, yellowish plaques over both eyelids, painless and slowly enlarging over time.
  • Caused by high level of LDL (Low Density Lipoprotein) cholesterol
A

Xanthelasma

HA LEC [Midterms] (5 decks)

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