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Nurs 252 > Assessment Of The Skin, Hair And Nails > Flashcards

Assessment Of The Skin, Hair And Nails Flashcards

1
Q

Acute assessment of skin

A

-pressure ulcers
-severe dehydration
-acute injury (burns/wounds)
-cyanosis
-infection

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2
Q

Subjective data of skin

A

-personal/familial history of skin disease
-change in pigmentation
-change in mole
-excessive dryness, or moisture
-bruising, itching, rash or lesions

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3
Q

Risk assessment and health promotion (topics/teaching)

A

Topics: skin cancer, and self examination

Teaching: sunscreen, vitamin D deficiency

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4
Q

Mole assessment

A

Asymmetry, boarder, color, diameter (>1cm), elevation,

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5
Q

Color assessment

A

-general pigmentation
-unexpected changes

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6
Q

Impact skin color

A

-temperature
-emotional state
-prolonged elevation or dependant (positioning)
-inactivity/activity

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7
Q

Paller

A

Pale
-different depending on baseline skin color

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8
Q

Erythema

A

Redness
-can be pink, red

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9
Q

Localized paller

A

Blood flow to area

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10
Q

Central/systemic paller

A

Shock/anemia

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11
Q

Localized cyanosis

A

Cold, anxiety

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12
Q

Central/systemic cyanosis

A

Dec Cardio pulmonary

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13
Q

Localized jaundice

A

Sclera, hand, palate, mucus membranes

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14
Q

Central/systemic jaundice

A

Liver affecting the skin

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15
Q

Localized Carotinemia

A

Babies: from eating orange

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16
Q

Central/systemic brown/tan skin

A

Hemochrometosis (provide iron) and additions disease (inc in melanin)

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17
Q

Localized warm spot

A

Could be infection

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18
Q

Localized cold spot

A

Decreased circulation, legs PVD

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19
Q

Assessment of moisture and texture

A

-palmar surface of fingers and hand
-consistency

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20
Q

Edema

A

Press firmly for 5 seconds
-if indentation remains, grade on 4 point scale

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21
Q

Skin mobility and turbot

A

Grasp skin between thumb and index finger, skin should return

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22
Q

Vascularity or bruising

A

-multiple contusions
-cherry angiomas (normal)
-varicosities

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23
Q

Inspecting hair

A

-hair loss = malnourished, vitamin deficiencies
-color, texture

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24
Q

Clubbing

A

-nail diamond test
-nail feels spongy

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25
Q

Inspect nail

A

Shape, color, thickness, consistency, capillary refill

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26
Q

Developmental considerations: infants

A

Skin: birthmarks, erythematous states, cyanosis conditions, carotenemia, vernix, lanugo, physiologic jaundice, milia
Hair: cradle cap

Risk for fluid loss, poor temperature regulation

27
Q

Developmental consideration: children

A

Skin: dryness, rashes, bruising
Hair: lice, dry scalp
Nails: brittle nails

28
Q

Developmental consideration: adolescents

A

Skin: acne, cutting, infected piercing, tattoos
Hair: brittle hair, lice
Nails: brittle nails or injuries to nails

29
Q

Developmental consideration: adults

A

Skin: itchiness, rash, moles, lesions, dry skin
Hair: hair loss, brittle hair
Nails: brittle nails, loss of nail, nail defects

30
Q

Developmental consideration: pregnant women

A

Skin: PUPP, striae, linea nigra, melasma
Hair: brittle or thicker due to hormonal changes
Nails: brittle or stronger due to hormonal changes

31
Q

Developmental consideration: older adults

A

Skin: itchiness, dryness, tearing, bruising, decreased turgor
Hair: loss of hair, brittle har
Nails: brittle nails, splitting, clubbing, longitudinal ridging

32
Q

Mongolian spots

A

Indigenous babies may be born with spots

33
Q

Subcutaneous

A

Adipose tissue
-fat cells (storage for energy, insulation, protection)

34
Q

Sebaceous glands

A

Produce protective lipid, sebum (lubricates skin and hair)

35
Q

Eccrine glands

A

Produce sweat

36
Q

Apocrine

A

Secret thick milky substance
-emotional and sexual arousal

37
Q

Senile purpura

A

As you age sweat glands and sebaceous glands decrease in number and function, leaving the skin dry
-if a minor trauma occurs it could cause dark red discoloured areas

38
Q

Cherry senile angioma

A

Small smooth, slightly raised bright red
-not significant

39
Q

Mongolian spot

A

Common variation of hyperpigmentation in newborns of indigenous, African, East Indian or Hispanic descent
-blue blac purple macular area at sacrum or buttocks

40
Q

Erythema toxicum

A

Common rash appearing in first 3/4 days of life

41
Q

Keratoses

A

Lesions are raised, thickcend areas fo pigmentation looking scaly and warty

42
Q

Vitiligo

A

Patchy depigmentation from destruction of melanocytes

43
Q

Annular

A

Circular, begins in center and spreads
-ringworm

44
Q

Confluent

A

Lesions that merge together
-hives

45
Q

Discrete

A

Distinct, individuals lesions that remain separate

46
Q

Grouped

A

Clusters of lesions

47
Q

Gyrate

A

Twisted, coiled, spiral snakelike

48
Q

Target

A

Iris
-resembles iris of eye, concentric rings of colour in the lesions

49
Q

Linear

A

Scratch, streak, line or stripe

50
Q

Polycyclic

A

Annular lesions that grow together
-psoriasis

51
Q

Zosteriform

A

Linear arrangement along a nerve route
-herpes zoster

52
Q

Macule

A

Solely a colour change, flat and circumscribed
<1cm

53
Q

Patch

A

Maculae’s >1cm

54
Q

Papule

A

<1cm
Raised bump, can be scaly, well defined

55
Q

Nodule

A

Solid, elevated, hard or soft
>1cm

56
Q

Vesicle

A

Elevated cavity, contain free fluid, up to 1cm

57
Q

Cyst

A
58
Q

Pustule

A

Cavity filled with turbid fluid, circumscribed and elevated

59
Q

Fissure

A

Linear crack with abrupt edges
-dry or moist

60
Q

Erosion

A

Scooped out part of skin, depression
-epidermis lost
-no bleeding

61
Q

Excoriation

A

Self inflicted abrasion, superficial
-itching, scratching

62
Q

Atrophic scar

A

Depression, result of loss of tissue/thinning of epidermis

63
Q

Lichenification

A

Thickening of skin with production of tightly packed sets of papules, prolonged intense scratching

64
Q

Keloid

A

Hypertrophic scar, elevated, excess tissue beyond site of original injury

Nurs 252 (8 decks)

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