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NURS 2910 > Hair, Skin, and Nails Assessment > Flashcards

Hair, Skin, and Nails Assessment Flashcards

1
Q

Skin is the largest single organ of the body T or F

A

TRUE

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2
Q

Epidermis

A

outer layer of the skin

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3
Q

Dermis

A

lower layer of the skin

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4
Q

Subcutaneous tissue

A

loose connective tissue

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5
Q

Appendages of the integumentary system

A

hair, nails, sebaceous and sweat glands

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6
Q

Sebum

A

oily substance, waterproofs and protects the hair and skin

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7
Q

Function of the skin

A
  • protection
  • sensation
  • regulation
  • secretion/excretion> sweating
  • vit D formation
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8
Q

Risk Factors of the skin

A
  • Dampness
  • Dehydration
  • Nutritional status
  • Insufficient circulation
  • Skin diseases
    -Jaundice
  • Life style and personal choices
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9
Q

pruritis

A

itching

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10
Q

Maceration

A

-pruning of the skin
- prolonged moisture

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11
Q

Excoriation

A
  • Taking off superficial skin
  • Picking a scab
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12
Q

Abrasion

A

rubbing away of the epidermal level

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13
Q

Pressure injuries

A

lesions caused by tissue compression and inadequate perfusion

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14
Q

Acne

A

inflammation of the sebaceous gland

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15
Q

Developmental considerations for infants

A

Fragile skin

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16
Q

Developmental considerations for children

A

more resistant to injury and infection– need help with cleaning wounds

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17
Q

Developmental considerations for Adolescents

A

Sebaceous glands growing in size and increased sweat

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18
Q

Developmental considerations for Older adults

A
  • thinning epidermis
  • loss of elasticity
  • perspiration decreases
  • dry and scaly skin
  • hair thinner and more dry
  • thick, brittle nails
  • decreased melanin (brown spots)
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19
Q

What questions should you ask a patient who comes in with a new weird spot on their skin

A
  • Has it increased in size?
  • Does it itch?
  • How long have you had/ noticed it
  • Is it painful? What makes the pain better/ worse?
  • Have you seen this before?
  • Does it change in color?
  • History of skin disease?
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20
Q

HPI

A

History of present illness

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21
Q

Health history for the integumentary system can include…

A

bad sunburns, allergies, issues with nails, skin, hair

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22
Q

Lifestyle and Health practices can include…

A

piercings, tattoos, skin routine, makeup, bathing

23
Q

Working SBAR questions to ask for subjective data

A

Family history?
How long ago did you have a transplant?
How often is the patient repositioned?
How often are cares?
What factors affect nutritional status?
Good support system?

24
Q

What do you do to prepare a client for assessment

A
  • provide privacy
  • ask client to wear gown if applicable
  • comfortable sitting position
  • explain what you are going to do
25
What do you do to prepare a client for assessment?
- provide privacy - ask client to wear gown if applicable - comfortable sitting position - explain what you are going to do
26
Objective data: INSPECT
- color - mucous membranes - edema - lesions
27
Objective data: PALPATE
- skin temperature - turgor - texture - skin moisture/hydration
28
Normal Findings: INSPECT
- color: normal to skin tone - Mucous membranes: pink and moist - Edema: no edema present - Lesion: no lesions present
29
Normal Findings: PALPATE
- Skin temperature: warm, equally bilateral - Skin turgor: returns immediately, no tenting - Skin texture: smooth and soft - Skin moisture/hydration: warm and dry
30
Abnormal findings: INSPECT Color
-Pallor, jaundice, cyanosis - erythema(redness) - Ecclyymois(bruising) - Petechiae(pinpoint spots) - Mottling(marbling)
31
Abnormal findings: INSPECT
-mucous membrane: dry and not pink - edema: any sign of edema - lesions: lesions present
32
Abnormal findings: PALPATE
-Skin temp: warmer or cooler - Turgor: decreased or increased turgor - Skin texture: coarse, thick, dry or smooth, fine, shiny - Skin moisture/hydration: increased or decreased moisture
33
Describing skin lesions
- size - shape and pattern - color - distribution - texture - surface relationship( flat or raised) - exudates(drainage) - tenderness, pain or itching
34
Normal skin variations
-Milla(white spots on newborns) -Nevi(moles) - skin tags - striae(stretchmarks)
35
Primary skin lesions
- macule - Cyst - papule - Petechiae - Nodule - Pustule - Vesicle - Wheal
36
Macule
Flat, brown, less than 1cm, non-palpable ex. birthmark, freckles, petechiae
37
Papule
Elevated, palpable, solid mass ex. mole, psoriasis
38
Vesicle/ Bulla
- Elevated and filled with sebaceous fluid - Vesicle: Palpable, less than 1 cm in diameter - Bulla: greater than 1 cm ex. blisters and herpes
39
Cyst
Encapsulated, fluid-filled, palpable, less than 2 cm ex. keratogenous cyst
40
Pustule
Palpable, elevated, filled with puss ex. acne, impetigo, follicultis
41
Nodule
Elevated, solid, firm ex. wart, lipoma
42
Wheal
Elevated, superficial, edematous ex. insect bites, hives
43
Petechiae
Tiny pinpoint red or reddish-purple spots
44
ABCDE: Screening
A- asymmetry B- Borders C- color change D- Diameter less than or equal 5cm E- Elevation/enlargement
45
Skin conditions can look different on darker skin individuals T or F
TRUE
46
Braden Scale
Assessment tool to predict pressure sore risk
47
The Braden scale assesses 6 categories...
-Sensory perception - Moisture - Activity - Modality - Nutrition and friction - Shear
48
Objective data: HAIR
INSPECT/PALPATE - hair and scalp - color - texture - distribution - mobility - tenderness
49
Normal findings: HAIR
color: normal hair color Texture: normal texture can vary on find. distribution: evenly distributed mobility: scalp is smooth, no bumps tenderness: scalp is nontender
50
Abnormal findings: HAIR
color: albinism Texture: very dry and course or thinning distribution: generalized hair loss and hirsutism mobility: asymmetrical and lesions tenderness: tenderness present
51
Objective data: NAILS
- inspect color and shape - inspect and palpate texture - Assess capillary refill
52
Normal findings: NAILS
color and shape: nailbeds are level, firm, and similar to skin tone, shape is convex nail plate angle should be 160 degrees Inspect and palpate texture: smooth and uniform, surrounding tissue is smooth Assess cap refill: less than 3 seconds
53
Abnormal findings: NAILS
color and shape: black discoloration, pale/cyanotic nailbed, white spots, clubbing Inspect and palpate texture: thickened or brittle nails, soft boggy nails Assess cap refill: delayed, more than 3 seconds
54
Inspect and palpate integumentary systems includes
- color - moisture - turgor - lesions - edema - temperature - skin integrity - scarring - bruising

NURS 2910 (16 decks)

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