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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
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
26
Q

Objective data: INSPECT

A
  • color
  • mucous membranes
  • edema
  • lesions
27
Q

Objective data: PALPATE

A
  • skin temperature
  • turgor
  • texture
  • skin moisture/hydration
28
Q

Normal Findings: INSPECT

A
  • color: normal to skin tone
  • Mucous membranes: pink and moist
  • Edema: no edema present
  • Lesion: no lesions present
29
Q

Normal Findings: PALPATE

A
  • Skin temperature: warm, equally bilateral
  • Skin turgor: returns immediately, no tenting
  • Skin texture: smooth and soft
  • Skin moisture/hydration: warm and dry
30
Q

Abnormal findings: INSPECT Color

A

-Pallor, jaundice, cyanosis
- erythema(redness)
- Ecclyymois(bruising)
- Petechiae(pinpoint spots)
- Mottling(marbling)

31
Q

Abnormal findings: INSPECT

A

-mucous membrane: dry and not pink
- edema: any sign of edema
- lesions: lesions present

32
Q

Abnormal findings: PALPATE

A

-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
Q

Describing skin lesions

A
  • size
  • shape and pattern
  • color
  • distribution
  • texture
  • surface relationship( flat or raised)
  • exudates(drainage)
  • tenderness, pain or itching
34
Q

Normal skin variations

A

-Milla(white spots on newborns)
-Nevi(moles)
- skin tags
- striae(stretchmarks)

35
Q

Primary skin lesions

A
  • macule - Cyst
  • papule - Petechiae
  • Nodule - Pustule
  • Vesicle - Wheal
36
Q

Macule

A

Flat, brown, less than 1cm, non-palpable
ex. birthmark, freckles, petechiae

37
Q

Papule

A

Elevated, palpable, solid mass
ex. mole, psoriasis

38
Q

Vesicle/ Bulla

A
  • Elevated and filled with sebaceous fluid
  • Vesicle: Palpable, less than 1 cm in diameter
  • Bulla: greater than 1 cm
    ex. blisters and herpes
39
Q

Cyst

A

Encapsulated, fluid-filled, palpable, less than 2 cm
ex. keratogenous cyst

40
Q

Pustule

A

Palpable, elevated, filled with puss
ex. acne, impetigo, follicultis

41
Q

Nodule

A

Elevated, solid, firm
ex. wart, lipoma

42
Q

Wheal

A

Elevated, superficial, edematous
ex. insect bites, hives

43
Q

Petechiae

A

Tiny pinpoint red or reddish-purple spots

44
Q

ABCDE: Screening

A

A- asymmetry
B- Borders
C- color change
D- Diameter less than or equal 5cm
E- Elevation/enlargement

45
Q

Skin conditions can look different on darker skin individuals T or F

A

TRUE

46
Q

Braden Scale

A

Assessment tool to predict pressure sore risk

47
Q

The Braden scale assesses 6 categories…

A

-Sensory perception
- Moisture
- Activity
- Modality
- Nutrition and friction
- Shear

48
Q

Objective data: HAIR

A

INSPECT/PALPATE
- hair and scalp
- color
- texture
- distribution
- mobility
- tenderness

49
Q

Normal findings: HAIR

A

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
Q

Abnormal findings: HAIR

A

color: albinism
Texture: very dry and course or thinning
distribution: generalized hair loss and hirsutism
mobility: asymmetrical and lesions
tenderness: tenderness present

51
Q

Objective data: NAILS

A
  • inspect color and shape
  • inspect and palpate texture
  • Assess capillary refill
52
Q

Normal findings: NAILS

A

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
Q

Abnormal findings: NAILS

A

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
Q

Inspect and palpate integumentary systems includes

A
  • color
  • moisture
  • turgor
  • lesions
  • edema
  • temperature
  • skin integrity
  • scarring
  • bruising

NURS 2910 (16 decks)

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