skin

Question 1

fxn of skin

Answer 1

• Protection
• Prevents Penetration
• Perception
• Temperature Regulation
• Identification
• Communication
• Wound Repair
• Absorption & Excretion
• Production of Vitamin D

Question 2

hair

Answer 2

• Threads of keratin—hair shaft and bulb matrix
• Types of hair—vellus and terminal
• Follicle—cyclical with active and resting phases

Question 3

sebaceous glands

Answer 3

• Sebum—secreted lipid substance through hair follicles
• Lubricate skin and form emulsion

Question 4

sweat glands

Answer 4

• Eccrine produce sweat.
• Apocrine produce milky secretion and open into hair follicles

Question 5

nails

Answer 5

• Hard plates of keratin on dorsal edges of fingers and toes

Question 6

inspect and palpate

Answer 6

• Color
• General pigmentation
• Amounts of melanin
• Amounts of carotene
• Common pigmented areas
• Freckles
• Moles
• birthmarks

Question 7

inspect color and temp

Answer 7

• Color
  
  • Pallor (white)
  • Erythema (red)
  • Cyanosis (blue)
  • Jaundice (yellow)
• Temp
  
  • Use dorsal to palpate and check bilaterally
  • should be equal
    
    • hypothermia - low temp
    • hyperthermia - high temp

Question 8

inspect moisture, texture, and thickness

Answer 8

• moisture
  
  • perspiration on hands, face, axilla, and skinfolds in response to activity, a warm environment, or anxiety
    dehydration: notice in mucous membranes – should look smooth and moist
• texture: should feel smooth and firm with even surface
• thickness: epidermis is uniformly thin

Question 9

inspect and palpate for edema

Answer 9

• Fluid accumulating in intercellular spaces
• Not present normally
• Checked by imprinting thumbs firmly for 3-4 seconds against ankle malleolus or tibia
• Grade
  
  • 1+ Mild
  • 2+ Moderate
  • 3+ Deep
  • 4+ Very Deep
    
    • Scale is subjective
• May mask normal skin color and obscures pathologic conditions such as jaundice & cyanosis because the fluid lies between the surface and the pigmented layers

Question 10

inspect and palpate mobility and turgor

Answer 10

• Pinch up a large fold of skin under the clavicle (some also
  use skin over sternum)
• Mobility is the ease of rising
• Turgor is ability to return to place when released
• tenting = sign of dehydration

Question 11

inspect and palpate vascularity and bruising

Answer 11

• Document presence or absence
  
  • Cherry (senile) angiomas (small raised bright red dots)
    
    • Common in patients over age 30
• bruising

Question 12

inspect and palpate lesions

Answer 12

• If present, note
  
  • Color
  • Elevation (how tall in cm)
  • Pattern/shape (pattern (grouping) or all over body)
  • Size in centimeters (use ruler)
  • Location & distribution –> where is it? did it travel up the body?
  • Any exudates –> drainage –> how much? what color is it? what does it smell like?
• Palpate wearing gloves
• Use light/magnifier for closer inspection
• Use a Wood’s light for fluorescing lesions (fungal infections)

Question 13

inspect and palpate hair color and texture

Answer 13

• color
  
  • Color comes from melanin
    production
  • Graying begins as early as 3rd decade
  • Affected by genetics
• texture
  
  • Fine or thick
  • Straight, curly, kinky
  • Should look shiny

Question 14

inspect and palpate hair distribution and lesions

Answer 14

• distribution: fine vellus hair coats the body. coarse (eyebrows, eyelashes, and scalp)
• lesions: separate hair into sections and lift up to observe the scalp
  
  • inspect behind the ears and in occipital area
  • should be free from lesions or pest inhabitants

Question 15

inspect and palpate nails – shape and contour

Answer 15

• Normally slightly curved or flat
• Posterior & lateral folds are
  smooth
• Edges are smooth, rounded,
  & clean

Question 16

inspect and palpate nails – the profile sign

Answer 16

• Note angle of base of index
  finger at profile
  
  • ~160 degrees
  • Base is firm to palpation
  • Clubbing: angle is >180
    degrees

Question 17

inspect and palpate nails consistency, color, and capillary refill

Answer 17

• consistency
  
  • Surface is smooth & regular
  • Not brittle/ splitting
  • Thickness is uniform
  • Nail is firmly adhered to nail bed
• color
  
  • Nail plate is translucent
  • Bed underneath is pink
• capillary refill
  
  • Depress edge to blanch
  • Color should return in less than 3 seconds

Question 18

profile sign: clubbing

Answer 18

• normal: 160 deg
• curved nail: 160 or less
• early clubbing: 180 deg

Question 19

ABCDE rule

Answer 19

• Asymmetry –> look the same on both sides
• Border Irregularities –> smooth, jagged, irregular
• Color variation –> red in some spots brown in others
• Diameter >6mm
• Elevation/enlargement –> taller = more likely to worry abt

Question 20

subjective data – history of current symptoms

Answer 20

• Experiencing current skin problems?
• Describe birthmarks, tattoos, or moles
• Change in ability to feel pain, pressure etc.
• Any pain, itching, numbness?
• Hair loss or change in condition of hair
• Any change in condition of nails?

Question 21

subjective data – past health history

Answer 21

• what issues? how were they? what did you do?
• Describe any previous problems
• Diaper rash (only for children), burns, bruises, acne
• Any delayed wound healing
• Question potential allergic reactions
• Any fever, N/V, GI, or respiratory problems?

Question 22

subjective data – family health history

Answer 22

• Anyone had a recent illness, rash, or allergy?
• Anyone had skin cancer

Question 23

subjective data – lifestyle and health practices

Answer 23

• Question exposure to elements (sun & cold)
• Question daily routine for skin, hair & nails
• Question use of products for skin, hair, & nails
• Question food & fluid consumption
• Question pregnancy & regular menstruation –> hormonal changes changes skin
• Question stress

Question 24

objective assessment

Answer 24

• Client Preparation
  
  • Remove all clothing and jewelry
  • Don examination gown
  • Remove nail enamel, artificial nails, wigs, toupees & hairpieces
  • Have client sit comfortably on exam table
  • Provide for privacy & modesty
  • Observe any cultural considerations
  • Clients from conservative religious group may require nurse be the same sex as client

Question 25

equipment and supplies

Answer 25

- strong direct light (natural daylight = ideal) - penlight - mirror for client's self-exam of skin - magnifying glass - cm ruler - gloves (ALWAYS! Never know if something is contagious) - Wood's light (filtered UV light) - exam gown

Question 26

The nurse assessing a client’s skin turgor should gently pinch the skin over which area?

Answer 26

- clavicle