Skin, Hair, & Nails Flashcards
You can see a lot of ___ ___ via the patient’s skin
red flags
Do NOT ____ the skin
overlook
If you overlook the skin, you could possible miss many ____ ____ regarding what’s going on inside the body.
important clues
What are the 3 skin clues?
Respiratory problems (circulatory & breathing)
Cardiac problems
Dehydration
Respiratory Signs in Skin
Pallor or “pale” (typically notice in eyes)
Cyanosis (bluish discoloration)
Clubbing
Decreased capillary refill
Blue or Purple discoloration
Cyanosis
Where can cyanosis be seen?
Lips, nose, cheeks, ears, and oral mucous membranes (inside of mouth)
Cyanosis is a late sign of what?
respiratory distress
Is cyanosis always a reliable indicator?
No
Why is cyanosis not always reliable?
Because some patients never turn blue if they are dead (mainly in anemic patient b/c they lack red blood cells)
If hemoglobin is ___, it’ll be impossible for them to become cyanotic.
< 5
Bulging of distal fingers and nail beds
Clubbing
In clubbing, what do the nail beds feel like?
spongy (lots of abnormal movement)
Clubbing can be associated with many diseases such as..?
pulmonary
cardiac
neoplasms
Is it possible for clubbing to go away?
could possibly go back to normal if the issue going on can be fixed
Normal Capillary Refill
Color should return within 2 seconds
Decreased Capillary Refill
Sluggish return indicates respiratory or cardiac dysfunction
Capillary Refill determines what?
the heart pumping blood back in
Cardiac Signs
All the respiratory signs
Cool Temperature (peripheral tissue not being filled w/warm blood)
Diaphoresis (sweating)
Edema
Fluid accumulation in the interstitial spaces of dependent areas (e.g., feet, ankles, sacrum)
Edema
Edema can be a sign if the ___ isn’t working well
heart
Procedure for checking for Edmea
Press firmly for 3-4 seconds on tibia or ankle malleolus & let go. If it dents or dips in, it is edema.
Bilateral edema can indicate….?
heart or kidney failure
Edema Scale:
What is 1+ ?
Mild Pitting
slight indentation; no perceptible swelling of the leg
Edema Scale:
What is 2+?
Moderate Pitting
Indentation subsides rapidly
Edema Scale:
What is 3+?
Deep Pitting (Indentation remains for a short time; leg looks swollen)
Edema Scale:
What is 4+?
Very Deep Pitting
Indentations lasts a long time; Leg is very swollen
Dehydration Signs
Dry mucous membranes (dry mouth, dull)
Poor skin turgor (skin does not bounce back once pinched gently)
What should the Mucous Membrane normally look like?
smooth and moist
When assessing the mucous membrane, what should you assess?
the oral mucous membrane
When assessing skin turgor, what should you do and where?
gently pinch under the clavicle
Where should you assess skin turgor in infants?
the abdomen
Normal skin turgor
skin should be mobile and return quickly when released
Miscellaneous signs
Jaundice and Malignant Skin Lesions
Yellowish Skin color
Jaundice
Jaundice would be first noted on what parts of the body?
the hard and soft palate
sclera
Jaundice is associated with what?
liver dysfunction and some blood disorders
Would the patient be jaundice in one area of the body?
No, they would be jaundice in every area
Malignant Skin Lesions
ABCDE
A - asymmetry (has to be perfectly symmetric)
B - border irregularity
C - color variation (one solid color)
D - Diameter > 6mm (want to be smaller than 6mm)
E - Elevation or evolution (if its growing or changing)
