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Health Assessment > Ch 11 Skin Hair And Nails Assessment > Flashcards

Ch 11 Skin Hair And Nails Assessment Flashcards

1
Q

What is the largest organ in the body?

what does it consist of?

what is the purpose or intent? (3 things one of them is what the system is aka )

A

The integumentary system (skin) is the largest organ of the body

Composed of hair skin nails and sweat glands

Intent is:

  • to protect from pathogens,
  • cushion body
  • be a window to other body systems
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2
Q

What does it mean for the integumentary system to be a window to other body systems and give examples of how it is a window

A

It means it provides systemic data on the condition of the patient

Thermoregulatory: temperature/ febrile
Respiratory: cyanosis (blue)
Cardiovascular: pallor, red, blue, yellow
GI: jaundice to sclera (hepatic issue)
Neurological: having sensation, moving, REFLECTS STATUS OF CONDITION

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3
Q

How does the integumentary system reflect status of condition (what are a few things the skin can reflect w/o pt telling you a word)

A

Hydration: poor skin turgor or edema

Nutrition: malnourished or emassiated

Emotional: stress, anxiety, hives

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4
Q

Give the 3 layers of the skin

A
  1. Epidermis
  2. dermis
  3. Subcutaneous layer
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5
Q

Give all related information for the epidermis

including how many sub layers, function and its specialized cells purpose (think the fundamental aspect of fingers)

A

Epidermidis: top layer (has 5 total layers)

Function: first line of defense the pathogens(microorganisms) 1st layer:1st line

Epidermis specialized cells used for

  • perception of pain
  • light touch
  • vibration
  • temperature
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6
Q

 Give all related information for the dermis

Including sub layers, function and what it contains + bonus fact (TB)

A

Epidermidis: middle layer (2 sub layers)

Function: support Epidermis (takes it a step up and supports)

Contains blood vessels, sweat glands, hair follicles

 bonus fact: the dermis is where PPD TB test is administered

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7
Q

Give all related information to the subcutaneous layer

Including consistency, function and contribution

A

Subcutaneous layer: fat loose connective tissue

Function: provides insulation, calorie storage and cushioning v external factors

The subcutaneous layer helps with skin mobility

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8
Q

Give all related information for hair

Including what is composed of, function and what contributes to (M&F)

A

Hair is composed of keratin

Function: protects specific body areas and provides insulation

Contributes to gender identification
(I.e: men have facial hair, chest hair)

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9
Q

Where are the only Areas in the body where hair is not present

A

Hair is not present On the palms and soles

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10
Q

Give the two types of hair and their defining characteristics and location

as well as locations (M&W)

A
  1. vellus hair aka peachfuzz
    - tiny, short, fine, HYPOpigmented hair
    - Location: throughout body

2.terminal hair (standard hair)
-darker, kosher, noticeable hair, much longer
- Location: scalp, brows, eyelids 
W: axillae, perineum, legs
M: chest, abdomen, face

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11
Q

What is the hair change that occurs during puberty

A

In certain areas of the body vellus hair is turned to terminal hair during puberty

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12
Q

What is the name of the muscle that causes goosebumps and what instances does it happen in?

A

The arrector pili (erector) causes contraction that we call goosebumps and it could happen because of your environment (cold) or nerves

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13
Q

What kind of glands do hair have

A

Hair have sebaceous (Oil) glands that secrete sebum to:
-maintain hair moisture and condition
as well as
-prevent friction and shearing

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14
Q

What is the normal nail angle and what is the angle of clubbing as well as what does clubbing represent and what do you do if you inspect clubbing

A

Normal nail angle is 160 degrees

Angle of clubbing is anything over 160 most prominent 180

Clubbing represents CHRONIC HYPOXEMIA (further investigation is needed)
Could be respiratory or cardiovascular disorder

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15
Q

Diseased nails, describe

  1. Splinter hemmorage
  2. Half-and-half nail
  3. paronychia
  4. Onycholysis
A
  1. (Brown side with brown lines of longitudinal darkness through it)
    • results of endocarditis, damaged capillaries
  2. (Proximal portion white, distal portion pink)
    • result of chronic renal failure
  3. (Red infection surrounding nail cuticle, is swollen and tender)
    - result of and indicate infection
  4. (opaque White, yellow or green fungus separation of nail from nail bed)
    - result of nail fungus
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16
Q

How do you test capillary refill what does a test for and what is the appropriate amount of time to hold, then for blood to come back

A

Capillary refill test for perfusion of blood to fingers

Hold down each nail for five seconds and count how many seconds it takes to perfuse

Perfusion should be 2 to 3 sec

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17
Q

What is the function of sweat glands and what do they secrete

A

Function:
-thermal regulation (maintain body temp)

-evaporation and restoration of water

Swicklands secrete a weak saline (aka sweat) due to environment or physical stimuli

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18
Q

What are Apocrine glands and their location

What makes apocrine glands so unique (odor and how it comes about)

A

Apocrine glands= sex glands

  • located in axillae and genitals
  • unique because they excrete a milky sweat that combines with bacterial flora making a musky odor
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19
Q

Where are sebaceous glands located

what’s the purpose (how does it do this)

and what happens if they become inflamed

A

Sebaceous glands everywhere EXCEPT Palms and souls

Purpose is to Moisturize/ condition as well as prevent friction and shearing  through secretion of sebum


If inflamed sebaceous glands result in acne

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20
Q

What glands create acne when inflamed what is the typical ages for acne to be present

A

When sebaceous glands become inflamed it creates acne

Acne present from puberty (activation of sebaceous gland) to 17 years old

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21
Q

What is an open comedone

A

 Open comedones are blackheads because they are open to the skin

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22
Q

What are closed comedones

A

Close Comodomes are whiteheads because they’re closed by skin

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23
Q

What effect of aging creates the greatest risk for tears (think of the e main components)

A

Thinning of skin because of loss of elasticity, collagen and subcutaneous fat creates the greatest risk for tearing

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24
Q

Where do use for skin turgor on older populations

A

Skin turgor decreases access SUBclavicular

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25
Q

What does it mean to say older adults have a hair follicle atrophy

A

It means that white/gray hair is now being produced

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26
Q

What does the nails of an older adult look like

A

Older adults have sin brittle nails with slow growth

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27
Q

Why do elders have prolong wound healing And an increased risk of heat stroke

A

Elders have prolonged wound healing because of hypothermia within self and increased risk of heat stroke because of a decline in the interimmentary system

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28
Q

What are great places to assess skin turgor on older adults

A

Best : SUB clavicular

Over sternum or inner thigh

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29
Q

What is very common for newborns to have within the first 48 hours and why

A

It’s comment to a physiological jaundice in newborns for the first 48 hours because of an immature liver that can’t break down bilirubin yet

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30
Q

What layer is a baby born with and what does it protect from

(White thick substance you see in babies)

A

Babies are born with what is called vernix a layer to protect from amniotic fluid

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31
Q

What are body changing characteristics of a pregnant woman

Hormone,skin, glands

A
  1. Pregnant women have increased progesterone and estrogen
  2. Chloasma melasma “mask of preg”
    -A blotchy brown hyper pigmentation
    comment on face, Ariola, Vulva, inner thigh
  3. Hyper active sweat and sebaceous glands
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32
Q

What is lanugo and who has it

A

Lanugo is a fine hair covering found on newborns

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33
Q

How do you keep in mind cultural considerations when inspecting and doing assessment on patient

What do you never want to jump to conclusion on before inquiring about culture

A

Ask and inquire about any cultural practices when noticing unusual data

Never jump to the conclusion of abuse before inquiring about cultural practices

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34
Q

What is communication vital when noticing unusual data during assessment

A

Communications vital so weed the nurses gain an understanding

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35
Q

What is melasma and who is most likely to have it

A

Melasma is a blotchy hyperpigmentation (discoloration) common in pregnant but really anyone

36
Q

In the Arabic culture what is important for nurses to Consider culturally
(3 things: hair, skin, other person)

A
  1. Arabic women may not take off hijab if it is not related to complaint
  2. Patient may ask you to wear gloves before touching any part of skin

3. Arabic women may have the presence of a chaperone especially if healthcare worker is of opposite sex

37
Q

What is traction alopecia and who is it common in

A

traction alopecia is patchy hair loss due to tight braiding, weave use or tight ponytail

Common in African-Americans

38
Q

What is folliculitis barbae and who is it common in

A

Folliculitis barbae is ingrown hairs (beard) growing back into skin especially in curly hair

Common in African Americans

39
Q

What is a Mongolian spot and how does a differentiate from an ecchymosis (3 things)

A

A mongolian spot is a flat grayish blue spot on a newborn‘s butt or back legs

Mongolian spots fade over years, are one uniform color and are not tender unlike bruises that fade over days, are multiple colors, and are tender

40
Q

What culture has less body and facial hair

A

Southeast Asian

41
Q

If anything starts with Nevi or nevus What do you automatically know it is

A

A birthmark

42
Q

Who are henna tattoos common in

A

Arabic and Indian females

43
Q

What is cupping

What is coining

What are both commonly confused as outside of the Asian culture 

A

Cupping: are suction cup ecchymosis as therapeutic treatment 10-12 cups

Coining: is the removal/ scraping of the epidermis (dermal ablation) with a Guacha used as therapeutic treatment

I’ll tell the Asian culture cupping and cleaning are often confused for abuse

44
Q

What are healthy people 2020 goals for decreasing the rate of melanoma In relation to sun exposure and what a person should do to protect themselves

6 things

A
  • avoid sun between 10 AM- 4PM
  • use SPF 15 or + (PROTECTS FOR 150 min
  • apply 15 to 30 minutes per seun exposure
  • use SPF lip balm
  • Sunglasses with UVA/B protection
  • If swimming or sweating reapply every two hours
45
Q

Give UV index Numbers and risk of harm classification

A
  1. 0-2.9 : low: green
  2. 3.0-5.9 moderate: yellow
  3. 6.0-7.9: high: orange
  4. 8.0-10.9: very high: red
  5. 11+: Extreme: violet
46
Q

What are three scenarios that need emergency assessment and what will you see

Hydration, skin color and lacerations

A

Acute dehydration: skin tenting

Cyanosis: lack of O2, blue

Acute lacerations: avulsion, amputations 

47
Q

How do you treat an urgent (emergency) situation

2 steps if bleeding

A

First stop bleeding and apply pressure

48
Q

What is your concern when you see a suspicious lesions and what do you do

A

Think skin cancer

Do ABC DE and biopsy (if needed)

49
Q

When you see a rash and a fever together what do you think

If you administer an antibiotic how long should the patient remain around

A

Think infection

If given antibiotic patient remains around for 30 minutes to assess if reaction

50
Q

What vital signs are evident of hypovolemic shock

A

Hypotension: below 90/60

Tachycardia: above 100 bpm

51
Q

What is general information to gather when getting subjective data about skin including family issues

A

If the patient has noticed any difference in skin color, texture, hair, nails + Family history and any skin cancer

52
Q

When getting subjective data about skin issues what is important to ask in relation to medications and risk factors(Still in the realm of medication, over-the-counter)

A

 from medications ask of any prescriptions or allergies and the effects allergies cause

Risk factors include herbal supplements vitamins and over-the-counter medication

53
Q

What are things you should ask during the risk assessment in relation to the skin and skin cancer

Sun, skin quality,

A
  1. Any risk of sunburns like tanning
  2. Does patient have excessive exposure to sun
  3. How often does patient shower with hot water (compromised skin integrity)
  4. is patient bedbound
54
Q

What is the self skin examination and if the patient is not performing it already how do we teach and walked him through it

A

Self skin examination is what patient does at home to assess for any lesions or moles

Wlk thru:

  • completely Undress
  • stand in front of long mirror
  • Scan body using hand mirror to look at hard to see areas and tell them to use ABCDE
55
Q

If the patient has piercings or tattoos what is important to make patient aware of

A

Make patient aware of

  • infection signs and symptoms
  • Watch for for HIV, Hep C
  • piercing nerve damage
56
Q

What are common integumentary symptoms

Scratching, redness, cuts

A

Pruritus: itching (treat w/ Benadryl)

Rash: Macular, papular, urticaria

Skin lesion/wounds: keloids, tinea vesicular: hypo pigmentation in upper chest/back

57
Q

When is alopecia common in men and what do you assess if it happens before

A

Alopecia is common in men at age 40

If alopecia happens before 40 assess for 
-injuries to heads
-chemo radiation
-malnutrition
-hereditary
58
Q

What are you looking for when you were assessing your hair and what’s an important rule when it comes to hands

A

WEAR GLOVES!

When assessing hair you’re looking for pediculosis and nits

evident by oval dots about 1 inch from hair shaft

59
Q

What is candIDA and pattern
where are you most likely to find it
and who is most likely to have it

A

canDIDA is a fungus found between skin folds with moisture (satellite)

Likely found in the

  • axillae
  • under breasts ( inframammory area)
  • groin

Those overweight are most likely to have it

60
Q

What is another phrase for a complete skin assessment

A

Head to toe

61
Q

Where are objective data characteristics to look for when examining skin

A 
-Color -
texture 
-moisture 
-turgor 
-Temperature 
-normal and abnormal
62
Q

Define the Braden scale and give the six areas assessed

A

Braden scale assess the skin and territory and the likelihood of an ulcer developing

  1. Sensory perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction and sheer
63
Q

 give the Braden‘s scale score breakdown from total points to the risks

A

Total points: The higher the number is to 18 the less chance of an ulcer

Mild: 15 to 18+
Moderate: 13 to 14
High risk: 10 to 12
Severe: 9

64
Q

What is vital to do when inspecting the patient skin especially if they are bedbound

A

Turn to see patients back to visualize all body surfaces

65
Q

What are priority areas to inspect for ulcers

A

Bony prominences where pressure is applied and can develop into a decubitus ulcer:

  • coxa (hips)
  • thighbone (femur)
  • heels
66
Q

Where are primary areas to inspect for canDIDA

A

axillae
Under breast (inframammory area)
Groin

67
Q

What do primary lesions arise from and give a few examples (size and real example)

A

Primary lesions arise from normal skin
-maculae: 1cm freckles
-Papules: 1cm raised (wort)
-pustules: any size pimple
-vesicles: 1cm fluid filled (chicken pox/herpes)
-cherry angioma: 1cm raised red dot like papule

68
Q

At what age do cherry angiomas usually resolve

A

At age 9

69
Q

What do secondary lesions arise from or follow and examples

A

Secondary lesions arise from or follow primary lesions

  • scars
  • keloids
  • crusts
  • ulcer *
70
Q

Give an example of a vascular lesion and how it originates

A

Petechiae: red/ purple dots under skin

Because of embolism or leukemia

71
Q

Give to examples of inflammatory skin lesions

Makes people scratch

A
  1. Eczema

2. Contact dermatitis

72
Q

Briefly describe the five stages of a pressure ulcer (decubitus)

A

Stage 1. Intact skin Non-blanchable redness

Stage 2. partial thickness loss, dermis exposed, moist, blister may be intact or ruptured

Stage 3. Full sickness loss, may have epibole: rolled edges, slough and Eschar may be present.
May tunnel

Stage 4 : Full sickness loss, present: epibole, slough, eschar, tunneling

Stage 5: unstageable because of slough and eschar extent, dead tissue

73
Q

List the Wound classifications

A

Clean: surgical sterile

Clean contaminated: sterile but involves other systems

Contaminated: exposed to infected fluids

Infected: exposed to contaminants or infection

74
Q

Give the scale and numbers for measuring edema

A 
0 -no Edema 
\+1- 2mm
\+2- 4mm
\+3-6mm
\+4 -8 mm (pitting edema)
75
Q

Give the ABCDE of skin

A

A- asymmetry (do both side match)

B-order : (discrete or ragged)

C-olor : (uniform or variety)

D-iameter (+6mm)

E- volition (stagnant or rapid changes)

76
Q

What is the highest risk cancer and was so does it originate from

A

The highest risk cancer is melanoma originate from melanin cells

77
Q

What is scraping ( diag test)done with and why is it done

A

Scraping is done with a scalpel for microscopic examination

78
Q

What is culture and sensitivity done and what is it used for

A

Culture and sensitivity done with Q-tip

Identifies if any fungus is present in exudate

79
Q

What is the wood light test and where is it done

A

Wood test detects bacterial or fungal infections in the scalp using UV light

Any deviation from Violet is fungus

80
Q

Why is a biopsy done

A

Done to determine if benign or malignant suspicious lesions

81
Q

Give me a few nursing diagnosis related to skin

A

Impaired skin integrity
Impaired tissue integrity
Pain
Risk for infection

82
Q

What are a few nursing outcomes related to skin

A

Skin mucous membrane intact

Patient demonstrate measures to protect and heal

83
Q

Give interventions related to skin

A

Improve patient status by assessing skin and risk for breakdown

84
Q

What does the Wallace rule of nines estimate

A

The depth and The total body surface area percentage burned in adults

85
Q

Give the Wallace rule of nines for the entire body

A 
Head: 9
Arms: 9 each
Trunk (front) : 18 truncated back: 18
Legs: 18 each 
Genitalia: 1

Health Assessment (20 decks)

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