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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
Inspect nail
Shape, color, thickness, consistency, capillary refill
26
Developmental considerations: infants
Skin: birthmarks, erythematous states, cyanosis conditions, carotenemia, vernix, lanugo, physiologic jaundice, milia Hair: cradle cap Risk for fluid loss, poor temperature regulation
27
Developmental consideration: children
Skin: dryness, rashes, bruising Hair: lice, dry scalp Nails: brittle nails
28
Developmental consideration: adolescents
Skin: acne, cutting, infected piercing, tattoos Hair: brittle hair, lice Nails: brittle nails or injuries to nails
29
Developmental consideration: adults
Skin: itchiness, rash, moles, lesions, dry skin Hair: hair loss, brittle hair Nails: brittle nails, loss of nail, nail defects
30
Developmental consideration: pregnant women
Skin: PUPP, striae, linea nigra, melasma Hair: brittle or thicker due to hormonal changes Nails: brittle or stronger due to hormonal changes
31
Developmental consideration: older adults
Skin: itchiness, dryness, tearing, bruising, decreased turgor Hair: loss of hair, brittle har Nails: brittle nails, splitting, clubbing, longitudinal ridging
32
Mongolian spots
Indigenous babies may be born with spots
33
Subcutaneous
Adipose tissue -fat cells (storage for energy, insulation, protection)
34
Sebaceous glands
Produce protective lipid, sebum (lubricates skin and hair)
35
Eccrine glands
Produce sweat
36
Apocrine
Secret thick milky substance -emotional and sexual arousal
37
Senile purpura
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
Cherry senile angioma
Small smooth, slightly raised bright red -not significant
39
Mongolian spot
Common variation of hyperpigmentation in newborns of indigenous, African, East Indian or Hispanic descent -blue blac purple macular area at sacrum or buttocks
40
Erythema toxicum
Common rash appearing in first 3/4 days of life
41
Keratoses
Lesions are raised, thickcend areas fo pigmentation looking scaly and warty
42
Vitiligo
Patchy depigmentation from destruction of melanocytes
43
Annular
Circular, begins in center and spreads -ringworm
44
Confluent
Lesions that merge together -hives
45
Discrete
Distinct, individuals lesions that remain separate
46
Grouped
Clusters of lesions
47
Gyrate
Twisted, coiled, spiral snakelike
48
Target
Iris -resembles iris of eye, concentric rings of colour in the lesions
49
Linear
Scratch, streak, line or stripe
50
Polycyclic
Annular lesions that grow together -psoriasis
51
Zosteriform
Linear arrangement along a nerve route -herpes zoster
52
Macule
Solely a colour change, flat and circumscribed <1cm
53
Patch
Maculae’s >1cm
54
Papule
<1cm Raised bump, can be scaly, well defined
55
Nodule
Solid, elevated, hard or soft >1cm
56
Vesicle
Elevated cavity, contain free fluid, up to 1cm
57
Cyst
Encapsulated fluid filled cavity in dermis or subcutaneous layer
58
Pustule
Cavity filled with turbid fluid, circumscribed and elevated
59
Fissure
Linear crack with abrupt edges -dry or moist
60
Erosion
Scooped out part of skin, depression -epidermis lost -no bleeding
61
Excoriation
Self inflicted abrasion, superficial -itching, scratching
62
Atrophic scar
Depression, result of loss of tissue/thinning of epidermis
63
Lichenification
Thickening of skin with production of tightly packed sets of papules, prolonged intense scratching
64
Keloid
Hypertrophic scar, elevated, excess tissue beyond site of original injury
65
Plaque
Papuans that coalesce to form surface elevation wider than 1cm
66
We Hal
Superficial raised transient erythematous irregular shape
67
Urticaria or hives
Wehals that collapse to form extensive reaction

Nurs 252 (13 decks)

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