Health assessment-test 2-skin, hair, nails Flashcards
What can skin clue you in to?
respiratory problems
cardiac problems
dehydration
What are the respiratory signs
pallor
cyanosis
clubbing
decreased capillary refill
Define pallor
pale: can occur with high stress like anxiety or fear; also from vasoconstriction from exposure to cold and from cigarette smoking and in the presence of edema
Define cyanosis
blue or purple discoloration due to decreased perfusion; not always a reliable indicator
Where is cyanosis best seen?
lips, nose, cheeks, ears, and oral mucous membranes
True or false: cyanosis is an early sign of respiratory distress.
false; it is a late sign
If hemoglobin is ___ ___, it is impossible to become cyanotic
< 5
some people _____ turn cyanotic. Why?
never; if not enough RBC, can’t turn blue
Clubbing is the _____ of _____ fingers and ____ ____
bulging
distal
nail beds
In clubbing, nail beds have a _____ feeling.
spongy; moves alot when fingernail is moved up and down
What kind of disorders is clubbing associated with?
pulmonary, cardia, neoplasms (chronic lung inflammation, bronchial tumors, congenital cyanotic heart disease, lung cancer, pulmonary disease)
Normal nail is ___ degrees. Early clubbing, the angle straightens to ____ degrees.
160 degrees or less
180 degrees
Capillary refill…
Sluggish return means?
Early and late signs?
color should return within 2 seconds
sluggish return indicates respiratory or cardiac dysfunction
Pale (early)
Blue (late)
How do you check for clubbing?
place fingers nail to nail; if you see a diamond there is no clubbing
Can clubbing be reversed?
yes, if the problem can be fixed. In cystic fibrosis, clubbing will not go away
GCR stands for what in documentation?
Good capillary refill
Cardiac signs include:
Pallor poor capillary refill clubbing cyanotic temperature (cool) diaphoresis (sweating--skin not perfusing) edema
Edema is caused by:
fluid accumulation in the interstitial spaces of dependent areas (feet, ankles, sacrum)
How do you check for edema?
press firmly for 3-4 seconds on tibia or ankle malleolus
Bilateral edema can indicate…
heart or kidney failure (one side may be an injury)
Edema scale 1+ 2+ 3+ 4+
1+ Mild pitting (slight indentation, no perceptible swelling of the leg)
2+ Moderate pitting (indentation subsides rapidly)
3+ Deep pitting (indentation remains for a short time; leg looks swollen)
4+ Very deep pitting (indentation lasts a long time; leg is very swollen)
dehydration signs:
dry mucous membranes (in mouth, membranes look dry, dull) Normal is smooth and moist.
poor skin turgor
Skin turgor can be assessed best…
under the clavicle for adults; in infants, assess the abdomen
What should skin turgor be like if it is normal?
mobile and return quickly when released
Scleroderma
arm and leg area feel like a cast, very hard
Jaundice
Yellowish skin color
Where is jaundice first noted?
at the junction of the hard and soft palate and the sclera
What is jaundice associated with?
liver dysfunction and
some blood disorders (sickle cell dz)
Malignant skin lesions graded by what scale?
A = Assemetry B = border irregularity C = Color variation (don't want variation; one color) D = diameter > 6 mm E = elevation or evolution (growing or changing)
Cafe au lait
tan to light brown, irregular shape, oval patch with well-defined borders (some diseases related to)
caused by increased melanin pigment in basal cell layer
Lesions have common shapes/configurations.
Name four:
Confluent–lesions run together (hives)
Discrete–distinct, individual lesions that remain separate (skin tags, acne)
Target–or iris; round shape center is different color; resembles iris of eye, concentric rings of color in lesions (erythema multiforme)
Zosteriform–linear arrangement along a unilateral nerve route (herpes zoster)
Macule
freckle/flat mole; darker color; less than 1 cm (freckles, flat nevi, measles, scarlet fever)
papule
something you can feel; solid, elevated, circumscribed; less than 1 cm (mole, wart)–you can palpate a papule
nodule
solid, elevated, hard or soft, larger than 1 cm; may extend deeper into dermis than papule (fibroma)
tumor
larger than a few cm; firm or soft; can be benign (lipoma, hemangioma)
vesicle
elevated cavity containing free fluid; up to 1 cm (herpes, chicken pox (early), shingles)
uticaria (hives)
wheals coalesce to form extensive reaction; intensely pruritic
wheal
superficial, raised, transient and erythematous; slightly irregular shape from edema (mosquito bite, allergic reaction)
crust
thickened, dried out exudate left when vesicles/pustules burst or dry up; can be red-brown, honey or yellow
erythema
redness of the skin
lesion
any abnormality of skin
Four stages of pressure ulcers
TEST QUESTION
Stage 1: intact skin; appears red, not broken; will usually heal
Stage 2: skin breaks; shallow; looks like open blister or abrasion
Stage 3: ulcer extends into subcutaneous tissue and resembles crater (won’t see muscle, bone or tendon, but may see fat)
Stage 4: involves all skin layers; exposes bone, muscle, tendon; no pain because nerves are dead
Where do adults and children normally get pressure ulcers
elbows, sacrum, bones of bottom…anywhere with bone-y prominences
Babies– get pressure ulcers from medical equipment
pattern injury
bruise or wound whose shape suggests the instrument or weapon that caused it (can suggest child abuse)
bruise
mechanical injury resulting in hemorrhage into tissues; skin intact; ranges in color
petechiae
bleeding from superficial capillaries; can tell if this is blood is by pressing on it. If it does not turn white then you know it is petechiae (can use a glass to look thru to see)
ecchymosis
purplish patch resulting from extravasation of blood into skin; >3mm
psoriasis
scaly, erythematous patch with silvery scales on top
