Skin, Hair & Nail Assessment Flashcards
color assessment (4)
1) pallor: white color to skin
- hypertension, insufficient pre-load
- in mucous membranes
2) cyanosis: blueish color to lips & nails
- hypoxia (low-oxygen)
3) jaundice: yellow in sclera (supposed to be white)
- excess belly reuben
4) erythema: redness
- edema, (palpate for heat & warmth)
- heels, sacrum
how to assess dark-skinned patients
assess areas where pigmentation occurs the least
- pallor in mucous membranes
- erythema by palpating for warmth & heat
moisture assessment (5)
1) hydration
2) diaphoresis
3) flaking, scaling, or crusting
4) dryness
5) excessive dryness
hydration
moisture assessment
- dryness
- oiliness
diaphoresis
moisture assessment
= sweating
-perspiration
flaking, scaling, or crusting
moisture assessmnt
= dehydration
- more common in elderly
- overuse of soap
dryness
moisture assessmnt
- dehydration
- smoking
- stress
- sun exposure
excessive dryness
moisture assessmnt
- eczema (excessive dryness & itching)
- dermatitis (inflammation of dermal layer of the skin)
temperature assessment
- dependent on what
- best assessed how
- always compare what
- be alert to what
- dependent on amount of blood circulating through the dermis
- best assessed through PALPATION
- compare symmetrical body parts
- be alert to areas of warmth and erythema (could be stage 1 pressure ulcer)
Braden scale assesses what
-max & how low for a nursing intervention
- scale for pressure sores
- max 23
- 18 or lower -> intervention
6 components of Braden scale scoring
1) sensory perception ex/ dementia, paralysis on one-side 2) moisture ex/ person in diaper 3) activity level ex/ walk=4 bed rest=1 4) nutrition: usual food intake pattern 5) friction & shearing: mvmnt in bed
texture assessment
(how skin feels)
-smooth, rough, thin, thick, tight, indurated, scarred, wrinkled
turgor assessment (3)
1) elasticity
- edema, dehydration, age
2) pink skin & release fold on forearm & sternal bone
3) tenting: poor skin turgor/dehydration
vascularity assessment
-observe for reddened, pink or pale areas
petechiae
- red or purple spots
- may indicate blood clotting disorders (coagulation: can’t clot properly), drug reactions, or liver disease
- small hemorrhages
edema assessment
- edema may be secondary to what
- more common where
- observe and palpate for fluid build up in tissues
- secondary to: direct trauma or impaired venous return = PRELOAD
- common in dependent areas
edema: if indentation remains after 5 seconds its called what
- whats the scale
-pitting edema
+1 = 2mm deep
+2 = 4mm
+3 = 6mm
melanoma is what
-what do you use to assess warning signs
-deadliest form of skin cancer
-begins as small, mole like growth
ABCD:
-asymmetry
-border iregularity
-color variation from blue to black
-diameter greater than 6 mm
hair assessment
- observe
- color, quantity, thickness, texture, hirsutism (abnormal hair growth: women w/ facial hair)
clubbing indicates what
- COPD
- chronic low oxygen levels
cap refill assessment
-normal & abnormal
- press on nail & release
- normal: 2 seconds
- peripheral vascular disease
- arterial blockage
- heart failure
- shock
