Health Assessment #2 - Skin, Hair, and Nails; Head, Face, and Neck (2) Flashcards
Inspect and Palpate the Skin - Color
________ : observe the skin tone, normally it is even and consistent. May see freckles, moles (AKA nevus) or birthmarks.
General Pigmentation
Inspect and Palpate the Skin - Color
_______ : When the red pink tones from the oxygenated hemoglobin in the blood are lost, the skin looks white. Common in acute high-stress states such as anxiety or fear, due to powerful vasoconstriction from the sympathetic nervous system.
Can also turn white from _______ and _______. Look for pallor in mucous membranes, lips, and nail beds.
Pallor : When the red pink tones from the oxygenated hemoglobin in the blood are lost, the skin looks white. Common in acute high-stress states such as anxiety or fear, due to powerful vasoconstriction from the sympathetic nervous system.
Can also turn white from cold and cigarette smoking. Look for pallor in mucous membranes, lips, and nail beds.
Inspect and Palpate the Skin - Color
______ : is an intense redness of the skin from excess blood in the dilated capillaries. This is expected with ______, ______ or emotional reactions like blushing.
Erythema : is an intense redness of the skin from excess blood in the dilated capillaries. This is expected with fever, inflammation, or emotional reactions like blushing.
Inspect and Palpate the Skin - Color
______ : this is a bluish grey color that signifies ______.
The tissues do not have enough oxygenated blood. Most conditions causing this medical condition also cause decreased oxygenation of the brain, which will affect level of consciousness and show signs of respiratory distress.
Cyanosis : this is a bluish grey color that signifies low O2.
The tissues do not have enough oxygenated blood. Most conditions causing cyanosis also cause decreased oxygenation of the brain, which will affect level of consciousness and show signs of respiratory distress.
Inspect and Palpate the Skin - Color
______ : a yellowish skin color indicates a rising amount of bilirubin in the blood. Light/clay colored stools and dark golden urine usually accompany this medical condition. This medical condition is most often caused by ______.
Jaundice : a yellowish skin color indicates a rising amount of bilirubin in the blood. Light/clay colored stools and dark golden urine usually accompany jaundice. Jaundice is most often caused by liver disease.
Inspect and Palpate the Skin - Temperature
Use the ______ to palpate the person and check bilaterally. The skin should be warm, and the temp should be equal bilaterally. ______ and ______ may be slightly cooler.
Use the dorsal surface of both hands to palpate the person and check bilaterally. The skin should be warm, and the temp should be equal bilaterally. Hands and feet may be slightly cooler.
Inspect and Palpate the Skin - Temperature
______ : Generalized coolness, may be induced in cases such as a special surgery or a high fever.
Hypothermia : Generalized coolness, may be induced in cases such as a special surgery or a high fever.
Inspect and Palpate the Skin - Temperature
______ : generalized warmness, occurs with an increased metabolic rate, such as fever or heavy workout. A localized area may feel warm with a ______, ______, or sunburn.
Hyperthermia : generalized warmness, occurs with an increased metabolic rate, such as fever or heavy workout. A localized area may feel hyperthermic with a infection, ______, or sunburn.
Inspect and Palpate the Skin - Moisture
______, or profuse perspiration accompanies an increased metabolic rate.
Diaphoresis
Inspect and Palpate the Skin - Moisture
Look for dehydration in the oral mucous membranes. Normally, there is none, the mucous membrane should look ______ and ______.
Look for dehydration in the oral mucous membranes. Normally, there is none, the mucous membrane should look moist and smooth.
Inspect and Palpate the Skin - Texture
Normal skin feels ______ and ______ with an even surface.
Normal skin feels smooth and firm with an even surface.
Inspect and Palpate the Skin - Thickness
The epidermis is uniformly thin over most of the body, thickened calloused areas on the ______ or ______ are normal.
The epidermis is uniformly thin over most of the body, thickened calloused areas on the soles or palms are normal.
Inspect and Palpate the Skin
______ is fluid accumulating in the intercellular spaces; it is not present normally. To check for this medical condition, imprint your thumbs firmly against the ankle or the tibia. If your pressure leaves a dent in the skin, “pitting” edema is present and graded on a four point scale.
Edema is fluid accumulating in the intercellular spaces; it is not present normally. To check for edema, imprint your thumbs firmly against the ankle or the tibia. If your pressure leaves a dent in the skin, “pitting” edema is present and graded on a four point scale.
Inspect and Palpate the Skin - Edema
The four point scale:
- 1+ = ?
- 2+ = ?
- 3+ = ?
- 4+ = ?
The four point scale:
- 1+ = mild
- 2+ = moderate
- 3+ = deep pitting (visually noticeable)
- 4+ = very deep pitting
Inspect and Palpate the Skin - Mobility & Turgor
Pinch up a large fold of skin on the anterior chest under the ______.
______ is the skin’s ease of rising, and ______ is its ability to return to place promptly when released. This reflects the elasticity of the skin.
Pinch up a large fold of skin on the anterior chest under the clavicle.
Mobility is the skin’s ease of rising, and turgor is its ability to return to place promptly when released. This reflects the elasticity of the skin.
Inspect and Palpate the Skin - Vascularity or Bruising
______ are small, smooth, bright red dots that commonly appear on the trunk in all adults older than 30 years.
- Any bruising should be consistent with the expected trauma of life.
- There are normally ______ varicosities.
- Document any tattoos and inform them that they have an increased risk for ______.
Cherry angiomas (senile angioma) are small, smooth, bright red dots that commonly appear on the trunk in all adults older than 30 years.
- Any bruising should be consistent with the expected trauma of life.
- There are normally no varicosities.
- Document any tattoos and inform them that they have an increased risk for Hepatitis C.
Inspect and Palpate the Skin - Lesions (Pattern or Shape)
______ : example is Ringworm
Lesions (Don’t forget the A, B, C, D, E for abnormal lesions)
Circular** / **Annular : example is Ringworm
Inspect and Palpate the Skin - Lesions (Pattern or Shape)
______ : all running together, don’t know when one begins or ends. Example is hives.
Lesions (Don’t forget the A, B, C, D, E for abnormal lesions)
Confluent : all running together, don’t know when one begins or ends. Example is hives.
Inspect and Palpate the Skin - Lesions (Pattern or Shape)
______ : by themselves, comedo is acne
Lesions (Don’t forget the A, B, C, D, E for abnormal lesions)
Discrete : by themselves, comedo is acne
Inspect and Palpate the Skin - Lesions (Pattern or Shape)
______ : localized, example poison oak
Lesions (Don’t forget the A, B, C, D, E for abnormal lesions)
Grouped : localized, example poison oak
Inspect and Palpate the Skin - Lesions (Pattern or Shape)
______ : Looks like a bulls eye, due to a reaction of medication
Lesions (Don’t forget the A, B, C, D, E for abnormal lesions)
Target : Looks like a bulls eye, due to a reaction of medication
Inspect and Palpate the Skin - Lesions (Pattern or Shape)
______ : develops on nerves, example is shingles
Lesions (Don’t forget the A, B, C, D, E for abnormal lesions)
Zosteriform : develops on nerves, example is shingles
Inspect and Palpate the Skin - Lesions (ABCDE for abnormal lesions)
If any lesions are present, note:
- ?
- ?
- ?
- ?
- ?
- ?
If any lesions are present, note:
- color
- elevation: flat, raised
- pattern or shape
- size in centimeters
- location and distribution on body: generalized or localized
- Any exudate: note its color and odor
