Skin, Hair & Nail Assessment

Question 1

color assessment (4)

Answer 1

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

Question 2

how to assess dark-skinned patients

Answer 2

assess areas where pigmentation occurs the least

• pallor in mucous membranes
• erythema by palpating for warmth & heat

Question 3

moisture assessment (5)

Answer 3

1) hydration
2) diaphoresis
3) flaking, scaling, or crusting
4) dryness
5) excessive dryness

Question 4

hydration

moisture assessment

Answer 4

• dryness

- oiliness

Question 5

diaphoresis

moisture assessment

Answer 5

= sweating

-perspiration

Question 6

flaking, scaling, or crusting

moisture assessmnt

Answer 6

= dehydration

• more common in elderly
• overuse of soap

Question 7

dryness

moisture assessmnt

Answer 7

• dehydration
• smoking
• stress
• sun exposure

Question 8

excessive dryness

moisture assessmnt

Answer 8

• eczema (excessive dryness & itching)

- dermatitis (inflammation of dermal layer of the skin)

Question 9

temperature assessment

• dependent on what
• best assessed how
• always compare what
• be alert to what

Answer 9

• 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)

Question 10

Braden scale assesses what

-max & how low for a nursing intervention

Answer 10

• scale for pressure sores
• max 23
• 18 or lower -> intervention

Question 11

6 components of Braden scale scoring

Answer 11

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

Question 12

texture assessment

Answer 12

(how skin feels)

-smooth, rough, thin, thick, tight, indurated, scarred, wrinkled

Question 13

turgor assessment (3)

Answer 13

1) elasticity
- edema, dehydration, age
2) pink skin & release fold on forearm & sternal bone
3) tenting: poor skin turgor/dehydration

Question 14

vascularity assessment

Answer 14

-observe for reddened, pink or pale areas

Question 15

petechiae

Answer 15

• red or purple spots
• may indicate blood clotting disorders (coagulation: can’t clot properly), drug reactions, or liver disease
• small hemorrhages

Question 16

edema assessment

• edema may be secondary to what
• more common where

Answer 16

• observe and palpate for fluid build up in tissues
• secondary to: direct trauma or impaired venous return = PRELOAD
• common in dependent areas

Question 17

edema: if indentation remains after 5 seconds its called what
- whats the scale

Answer 17

-pitting edema
+1 = 2mm deep
+2 = 4mm
+3 = 6mm

Question 18

melanoma is what

-what do you use to assess warning signs

Answer 18

-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

Question 19

hair assessment

Answer 19

• observe

- color, quantity, thickness, texture, hirsutism (abnormal hair growth: women w/ facial hair)

Question 20

clubbing indicates what

Answer 20

• COPD

- chronic low oxygen levels

Question 21

cap refill assessment

-normal & abnormal

Answer 21

• press on nail & release
• normal: 2 seconds
• peripheral vascular disease
• arterial blockage
• heart failure
• shock