Module 8: Pt.1 Skin Hair and Nails assessment and terminology Flashcards
Developmental considerations for infants and children
thin, smooth skin.
Don’t sweat
can’t shiver
as they get older, body odour begins & pubic hair growth
Developmental considerations for infants and children
increased pigment in nipples, vulva ect.
They get stretch marks (Striae gravidarum) as a result of fragile CT
Increased metabolism and increased sweat,
increased fat in butt and hips
Developmental considerations for older adults
Skin less elastic Thin, fragile, dry and wrinkled Looses fat and muscle tone Wound healing delayed senile pupura Some facial hair self esteem loss
What is senile purpura
Red discoloured areas on older adults
What are striae gravidarum
Stretch marks
What subjective data would you collect for an integument assessment
1) Previous history of skin disease
2) Change in pigmentation
3) Changes in moles
4) Excessive dryness or moisture
5) Pruitus (severe itching)
6) Excessive bruising
7) Rash or lesion
8) Medications
9) Hair loss
10) Change in nails
11) Environmental or occupational hazards
12) Self care behaviours
What is psoriasis
Extra skin cells building up on surface of skin
What is pruritus
severe itching
Additional Subjective data for infants and children
1) Birthmarks
2) Change in skin colour
3) Rashes or sores
4) Diaper rash
5) Burns and bruises
6) Sun exposure
7) Self destructive habits
Additional subjective data for adolescence
Any skin problems (acne)
additional subjective questions for older adults
1) Skin changes
2) Wound healing and skin itching
3) Other skin pain
4) Foot changes
5) Falling
6) Diabetes and cardio vascular disease
7) Skin care
What is the main skin integrity assessment tool
The Braden Scale
What are the 6 Things that the braden scale measures
1) Sensory perception
2) Moisture
3) Activity
4) Mobility
5) Nutrition
6) Friction and sheer
Is a high or a low braden scale measure more susceptible to skin integrity risk?
The lower the braden scale the more risk
AKA, a 4 has a way higher chance of developing a skin abnormality than someone who is a 20
What are the additional risk factors mentioned in the braden scale
- Age over 80
- Exhisting skin breakdown
- Poor dietary intake of protein
- Hemodynamic instability
- Fever
- Diastolic pressure below 60
What objective data should Inspect during a skin assessment
1) Regional examination
2) Colour
3) Moles and their possible abnormalities
4) Temperature
5) Moisture
6) Texture
7) Thickness
8) Edema
9) Mobility and Turgor
10) Vascularity and bruising
11) Lesions
What is the regional examination
Looking at the whole body
locations the patient cannot see
inspect mucous membranes
What are different colour abnormalities you might see
Pallor, Cyanosis, Erythema, Jaundice, Brown-tan,
What are signs of danger in a mole? (ABCDE)
Assymetry, Border irregularity, Color Variation, Bigger than 6mm, elevation and enlargement, Itch burn or bleed
What is pallor
Pale skin or dull grey with no glow
-Sometimes caused by anemia, local artery insufficiency, shock
What is Cyanosis
A dusk blue grey or dull and lifeless
-increased unoxygenized blood, chronic heart and lung disease, exposure to cold, anxiety
What is erythema
Redness of the skin
- Can be caused by:
- Hyperemia: Increased blood flow
- Polycythemia: increased red blood cells
- Carbon monoxide poisoning
- Venous Stasis: (decreased blood flow from an area)
What is Jaundice
Yellowing of the skin
- Can be caused by:
- Liver or renal failure
- Eating carotene rich food
What is “Brown-tan” skin change indicate
- Addisons disease (Increased melanin)
- Cafe au late spots (increased melanin)
What is Diaphoresis
Profuse sweating (exercise or fever)
What can hyperthyroidism cause your skin to feel like
Smooth, velvet
What can hypothyroidism cause your skin to feel like
dry, crackly, rough
What is Edema
Fluid that accumulates in the intercellular spaces
What is unilateral edema
localized
What is bilateral edema
Generalized can mean heart or kidney failure
What is mobility
Skins ease of rising
What is Turgor
skins ability to return back to place
What is scleroderma
Hard skin, Chronic skin disorder with mobility decreased
What is Ecchymosis
A bruise
What is cherry angiomas
tiny bruises that can appear in older people
What to assess for when looking at lesions
1) Colour
2) Elevation
3) Pattern or shape
4) Size
5) Location and distribution
6) colour and odour
* Primary is when it developed on previously unaltered skin
* Secondary is when it changes
What should you palpate/ inspect the hair for?
1) Colour
2) Texture
3) Distribution
4) Lesions or lice
What is hirsutism
excessive body hair
What should you palpate and inspect the nails for
1) Shape and contour
2) Consistency
3) Color
What are macules and what are papules
macules are small and flat
where as papules rise up
What does nail clubbing mean
Possible congenital and chronic respiratory or heart disorder, disease chronic bronchitis
What are the 3 erythematous states for infants
1) 24hr beefy red vasomotor instability
2) harlequin colour change - Side laying position where the top is white and the bottom is red
3) Erethema toxicum - Tiny red macules and papules
What is acrocyanosis
Blue lips, hands and finger tips
What is cutis marmorata
cool temps, red or blue skin patterns
Jaundice in babies
Because of increased number of red blood cells that hemolyze.
On the 3rd or 4th day its normal but on the first day it can mean hymoltic disease
on the second week it can mean a bilateral tract obstruction
What is carotenemia
Orange or yellow (not in the sclera)
Will go away on its own
its from vitamin A and carotene
What is vernix caseosa (on baby when its born)
moist white cream cheese substance
What is meconium staining (on baby when its born)
green
When can babies start sweating
after a month
What is stork bite
Flat red or pink forehead or back of neck - fades over time
What is lined nigra ( in pregnant women)
Brown or black down the midline
What is chloasma (in pregnant women)
Brown on face
What are senile lentigines (in older adults)
These are liver spots from sun exposure
What are keratoses (in older adults)
These are raised, thickened, crusty and warty lesions
Premalignant
What is Xerosis
It is dry skin
What are acrochordons
skin tags
What is sebaceous hyperplasia
Raised yellow papule with pebbly look
