Ch 11 Skin Hair And Nails Assessment Flashcards
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 )
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
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
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
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)
Hydration: poor skin turgor or edema
Nutrition: malnourished or emassiated
Emotional: stress, anxiety, hives
Give the 3 layers of the skin
- Epidermis
- dermis
- Subcutaneous layer
Give all related information for the epidermis
including how many sub layers, function and its specialized cells purpose (think the fundamental aspect of fingers)
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
 Give all related information for the dermis
Including sub layers, function and what it contains + bonus fact (TB)
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
Give all related information to the subcutaneous layer
Including consistency, function and contribution
Subcutaneous layer: fat loose connective tissue
Function: provides insulation, calorie storage and cushioning v external factors
The subcutaneous layer helps with skin mobility
Give all related information for hair
Including what is composed of, function and what contributes to (M&F)
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)
Where are the only Areas in the body where hair is not present
Hair is not present On the palms and soles
Give the two types of hair and their defining characteristics and location
as well as locations (M&W)
- 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
What is the hair change that occurs during puberty
In certain areas of the body vellus hair is turned to terminal hair during puberty
What is the name of the muscle that causes goosebumps and what instances does it happen in?
The arrector pili (erector) causes contraction that we call goosebumps and it could happen because of your environment (cold) or nerves
What kind of glands do hair have
Hair have sebaceous (Oil) glands that secrete sebum to:
-maintain hair moisture and condition
as well as
-prevent friction and shearing
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
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
Diseased nails, describe
- Splinter hemmorage
- Half-and-half nail
- paronychia
- Onycholysis
- (Brown side with brown lines of longitudinal darkness through it)
- results of endocarditis, damaged capillaries
- (Proximal portion white, distal portion pink)
- result of chronic renal failure
- (Red infection surrounding nail cuticle, is swollen and tender)
- result of and indicate infection - (opaque White, yellow or green fungus separation of nail from nail bed)
- result of nail fungus
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
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
What is the function of sweat glands and what do they secrete
Function:
-thermal regulation (maintain body temp)
-evaporation and restoration of water
Swicklands secrete a weak saline (aka sweat) due to environment or physical stimuli
What are Apocrine glands and their location
What makes apocrine glands so unique (odor and how it comes about)
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
Where are sebaceous glands located
what’s the purpose (how does it do this)
and what happens if they become inflamed
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
What glands create acne when inflamed what is the typical ages for acne to be present
When sebaceous glands become inflamed it creates acne
Acne present from puberty (activation of sebaceous gland) to 17 years old
What is an open comedone
 Open comedones are blackheads because they are open to the skin
What are closed comedones
Close Comodomes are whiteheads because they’re closed by skin
What effect of aging creates the greatest risk for tears (think of the e main components)
Thinning of skin because of loss of elasticity, collagen and subcutaneous fat creates the greatest risk for tearing
Where do use for skin turgor on older populations
Skin turgor decreases access SUBclavicular
What does it mean to say older adults have a hair follicle atrophy
It means that white/gray hair is now being produced
What does the nails of an older adult look like
Older adults have sin brittle nails with slow growth
Why do elders have prolong wound healing And an increased risk of heat stroke
Elders have prolonged wound healing because of hypothermia within self and increased risk of heat stroke because of a decline in the interimmentary system
What are great places to assess skin turgor on older adults
Best : SUB clavicular
Over sternum or inner thigh
What is very common for newborns to have within the first 48 hours and why
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
What layer is a baby born with and what does it protect from
(White thick substance you see in babies)
Babies are born with what is called vernix a layer to protect from amniotic fluid
What are body changing characteristics of a pregnant woman
Hormone,skin, glands
- Pregnant women have increased progesterone and estrogen
- Chloasma melasma “mask of preg”
-A blotchy brown hyper pigmentation
comment on face, Ariola, Vulva, inner thigh - Hyper active sweat and sebaceous glands
What is lanugo and who has it
Lanugo is a fine hair covering found on newborns
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
Ask and inquire about any cultural practices when noticing unusual data
Never jump to the conclusion of abuse before inquiring about cultural practices
What is communication vital when noticing unusual data during assessment
Communications vital so weed the nurses gain an understanding
What is melasma and who is most likely to have it
Melasma is a blotchy hyperpigmentation (discoloration) common in pregnant but really anyone
In the Arabic culture what is important for nurses to Consider culturally
(3 things: hair, skin, other person)
- Arabic women may not take off hijab if it is not related to complaint
- 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
What is traction alopecia and who is it common in
traction alopecia is patchy hair loss due to tight braiding, weave use or tight ponytail
Common in African-Americans
What is folliculitis barbae and who is it common in
Folliculitis barbae is ingrown hairs (beard) growing back into skin especially in curly hair
Common in African Americans
What is a Mongolian spot and how does a differentiate from an ecchymosis (3 things)
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
What culture has less body and facial hair
Southeast Asian
If anything starts with Nevi or nevus What do you automatically know it is
A birthmark
Who are henna tattoos common in
Arabic and Indian females
What is cupping
What is coining
What are both commonly confused as outside of the Asian culture 
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
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
- 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
Give UV index Numbers and risk of harm classification
- 0-2.9 : low: green
- 3.0-5.9 moderate: yellow
- 6.0-7.9: high: orange
- 8.0-10.9: very high: red
- 11+: Extreme: violet
What are three scenarios that need emergency assessment and what will you see
Hydration, skin color and lacerations
Acute dehydration: skin tenting
Cyanosis: lack of O2, blue
Acute lacerations: avulsion, amputations 
How do you treat an urgent (emergency) situation
2 steps if bleeding
First stop bleeding and apply pressure
What is your concern when you see a suspicious lesions and what do you do
Think skin cancer
Do ABC DE and biopsy (if needed)
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
Think infection
If given antibiotic patient remains around for 30 minutes to assess if reaction
What vital signs are evident of hypovolemic shock
Hypotension: below 90/60
Tachycardia: above 100 bpm
What is general information to gather when getting subjective data about skin including family issues
If the patient has noticed any difference in skin color, texture, hair, nails + Family history and any skin cancer
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)
 from medications ask of any prescriptions or allergies and the effects allergies cause
Risk factors include herbal supplements vitamins and over-the-counter medication
What are things you should ask during the risk assessment in relation to the skin and skin cancer
Sun, skin quality,
- Any risk of sunburns like tanning
- Does patient have excessive exposure to sun
- How often does patient shower with hot water (compromised skin integrity)
- is patient bedbound
What is the self skin examination and if the patient is not performing it already how do we teach and walked him through it
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
If the patient has piercings or tattoos what is important to make patient aware of
Make patient aware of
- infection signs and symptoms
- Watch for for HIV, Hep C
- piercing nerve damage
What are common integumentary symptoms
Scratching, redness, cuts
Pruritus: itching (treat w/ Benadryl)
Rash: Macular, papular, urticaria
Skin lesion/wounds: keloids, tinea vesicular: hypo pigmentation in upper chest/back
When is alopecia common in men and what do you assess if it happens before
Alopecia is common in men at age 40
If alopecia happens before 40 assess for -injuries to heads -chemo radiation -malnutrition -hereditary
What are you looking for when you were assessing your hair and what’s an important rule when it comes to hands
WEAR GLOVES!
When assessing hair you’re looking for pediculosis and nits
evident by oval dots about 1 inch from hair shaft
What is candIDA and pattern
where are you most likely to find it
and who is most likely to have it
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
What is another phrase for a complete skin assessment
Head to toe
Where are objective data characteristics to look for when examining skin
-Color - texture -moisture -turgor -Temperature -normal and abnormal
Define the Braden scale and give the six areas assessed
Braden scale assess the skin and territory and the likelihood of an ulcer developing
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and sheer
 give the Braden‘s scale score breakdown from total points to the risks
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
What is vital to do when inspecting the patient skin especially if they are bedbound
Turn to see patients back to visualize all body surfaces
What are priority areas to inspect for ulcers
Bony prominences where pressure is applied and can develop into a decubitus ulcer:
- coxa (hips)
- thighbone (femur)
- heels
Where are primary areas to inspect for canDIDA
axillae
Under breast (inframammory area)
Groin
What do primary lesions arise from and give a few examples (size and real example)
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
At what age do cherry angiomas usually resolve
At age 9
What do secondary lesions arise from or follow and examples
Secondary lesions arise from or follow primary lesions
- scars
- keloids
- crusts
- ulcer *
Give an example of a vascular lesion and how it originates
Petechiae: red/ purple dots under skin
Because of embolism or leukemia
Give to examples of inflammatory skin lesions
Makes people scratch
- Eczema
2. Contact dermatitis
Briefly describe the five stages of a pressure ulcer (decubitus)
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
List the Wound classifications
Clean: surgical sterile
Clean contaminated: sterile but involves other systems
Contaminated: exposed to infected fluids
Infected: exposed to contaminants or infection
Give the scale and numbers for measuring edema
0 -no Edema \+1- 2mm \+2- 4mm \+3-6mm \+4 -8 mm (pitting edema)
Give the ABCDE of skin
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)
What is the highest risk cancer and was so does it originate from
The highest risk cancer is melanoma originate from melanin cells
What is scraping ( diag test)done with and why is it done
Scraping is done with a scalpel for microscopic examination
What is culture and sensitivity done and what is it used for
Culture and sensitivity done with Q-tip
Identifies if any fungus is present in exudate
What is the wood light test and where is it done
Wood test detects bacterial or fungal infections in the scalp using UV light
Any deviation from Violet is fungus
Why is a biopsy done
Done to determine if benign or malignant suspicious lesions
Give me a few nursing diagnosis related to skin
Impaired skin integrity
Impaired tissue integrity
Pain
Risk for infection
What are a few nursing outcomes related to skin
Skin mucous membrane intact
Patient demonstrate measures to protect and heal
Give interventions related to skin
Improve patient status by assessing skin and risk for breakdown
What does the Wallace rule of nines estimate
The depth and The total body surface area percentage burned in adults
Give the Wallace rule of nines for the entire body
Head: 9 Arms: 9 each Trunk (front) : 18 truncated back: 18 Legs: 18 each Genitalia: 1
