skin assessment exam 2 Flashcards
how does the nurse start the skin assessment? What kinds of questions should be asked?
- Ask Questions
- personal health history: history of rashes? lesions? itchy areas? changes in moles?
- family history: family rashes? skin cancer?
- social history: where do they work & live? (as it can have a big impact on their skin health)
what are the general principles of a skin assessment?
- privacy: make sure to give pt privacy
- good lighting
- examine each body part
- document everything & do it well
- what is the color and pigmentation of the skin
what are the two major steps of skin examination?
- inspect head to toe
- palpate skin
What should the nurse note when inspecting head to toe?
- color being distributed, hair distribution throughout body, lesions, scars
what should the nurse be looking for when palpating the skin?
- for skin texture, temperature, moisture, thickness
what are the expected findings for skin assessment?
- warm, dry, and intact
what does cool skin on lower extremities indicate?
- possible ischemia & hypoxia
what is cyanosis?
- decreased o2 and perfusion
what does cyanosis look like in dark skin tones?
- ashy, gray color, conjunctiva of the eye, mucous membranes & nail beds
what does cyanosis look like in lighter skinned ppl?
- bluish gray tone in nail bed, ear lobes, palm
what is ecchymosis?
- brusing
what does ecchymosis look like on darker skinned pt?
- deeper blush or black tone, difficult to see unless in lighter area
what does ecchymosis look like on lighter skinned pt?
- dark red, purple, yellow or green depending on age of bruise
what does jaundice look like in a dark sinned pt?
- yellow - green ish color, yellow eyes (sclera), palms of hands, & soles of feet
what does jaundice look like in light skinned pt?
- yellowish color of skin, eyes, fingernails, plums of hands, oral mucosa
what is pallor?
- when a pt has loss of color
what does pallor look like in dark skinned pt’s?
- skin tone appears lighter, loss of red skin tones
what does pallor look like in light skinned pt’s?
- pale skin, may appear white
when a nurse is assessing hair, what are they looking for?
- inspect & palpate scalp & hair
- surface characteristics
- hair distribution
- texture
- quality
- color
what is the expected finding surface characteristics of hair?
- smooth without flaking, scaling, redness, or lesions
what is expected finding for hair?
- Hair should be shiny, soft, think, course
what is edema? and what do you document when its found?
- indentation on skin surface left after applying pressure
- Document presence, depth and symmetry
how do nurses assess edema?
- put 2 fingers on the edema for 2 seconds
- However deep it is (2 mm, 4mm, 6mm, 8mm) is how to chart it `
what is peripheral vascular disease? and how can it effect hair distribution?
- PVD is a disorder of blood vessels that causes narrowing/blocking/spasms in the blood vessels
- PVD can affect perfusion to the skin resulting in abnormal hair distribution
