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Nursing Health Assessment > Skin, Hair, Nails Ch. 13 > Flashcards

Skin, Hair, Nails Ch. 13 Flashcards

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1
Q

Xerosis

A

skin dryness

Greek: ‘xero’ means ‘dry

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2
Q

Seborrhea

A

excessive discharge of sebum from the sebaceous glands.

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3
Q

Pruritus

A

itchy skin

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4
Q

vitiligo (vit-ih-LIE-go)

A

a disease that causes loss of skin color in patches

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5
Q

Nevus

A

moles

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6
Q

buccal mucosa

A

inside cheeks

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7
Q

acrocyanosis

A

blueness (hypoxia) of the extremities (the hands and feet)

normal in babies <12 hrs old

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8
Q

General cyanosis

A

blueness (hypoxia) of the entire body- not good

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9
Q

Jaundice (icterus)

what causes it?

A

yellowing of the palate and sclera followed by the skin

-liver dysfunction

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10
Q

Erythemia

A

inflammation, CO2 poisoning

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11
Q

what could cause pallor change?

A

shock, anemia,

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12
Q

Where can you look for color change in patients with dark skin?

A 
under tongue
palms
mouth
conjunctivae
sclera
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13
Q

How is Edema graded?

A

1+ - 4+ (deep to very deep)

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14
Q

Diaphoresis

A

excessive sweating

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15
Q

cherry angiomas

A

little red bumps, normal starting in middle age

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16
Q

Anasarca

A

overall edema

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17
Q

Edema

A

swelling in the interstitial fluid

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18
Q

Purulent

A

pus, milky an thinck

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19
Q

Serous exudate

A

serum, watery

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20
Q

Hemorrhagic exudate

A

Bloody

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21
Q

Serosanguinous

A

thin, pink, and watery (more watery than pus)

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22
Q

what is a symptom of hyper/hypothyroidism?

A

Hyper: incredibly smooth soft skin
Hypo: rough , dry, flaky skin

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23
Q

Turgor
good
poor
taut

A

ability of skin to return to place promptly
elastic
tenting- dehydration
scleroderma or edema

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24
Q

Scleroderma

A

Hardening of the skin is one of the most visible manifestations of the disease.
comes from 2 Greek words: “sclero” meaning hard, and “derma” meaning skin.

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25
Q

Keloid

A

excess scar tissue

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26
Q

Linea Nigra

A

line down the abdomen in pregnancy

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27
Q

A skin disorder that causes skin cells to multiply up to 10 times faster than normal. This makes the skin build up into bumpy red patches covered with silvery/ pink scaly patches.

A

Psoriasis

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28
Q

What 6 things do you do when assessing skin?

A

1- inspect for color, pigmentation
2- palpate for temp, moisture, texture, thickness, edema, turgor, vascularity, bruising
3- note lesions size, shape, configuration, size, location
4- inspect and palpate the hair for texture, distribution, lesions
5- inspect and palpate the nails for shape contour, consistency
6- teach skin self-exam

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29
Q

During the inspection and palpation of the nails, the shape contour should be what?

A

about 160 degrees

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30
Q

what is clubbing?
pitting?
Concave?

A
  • nail contour is >180 degrees, a symptom of late chronic pulmonary or cyanotic heart disease
  • a symptom of psoriasis
  • a symptom of anemia
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31
Q

How do you do a Cap Refill test?

what are you testing?

A

peripheral circulation
depress nail bed for 5 seconds then release
color return in < 2 seconds = normal (can be an indication of shock)

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32
Q

How do you do a self skin exam?

A

ABCDEF

  • Asymmetry
  • Border
  • Color change
  • Diameter (>6mm, the size of a pencil eraser)
  • Evolving
  • Funny looking
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33
Q

Vernix Caseosa

A

cheesy substance covering a baby when born. Normal, do not wipe off

34
Q

Lanugo

A

downy hairs covering a new born (typically preterm) babies body, sheds in a few months

35
Q

Milia

A

sm. white spots on face, do not pop

36
Q

Mongolian Spots

A

Purple pigmentation on babies buttock, abdomen, arms or legs.
90% of black babies are born with this, do not mistake for bruising!!

37
Q

Mongolian Spots vs Bruising

A

Mongolian Spots: ill defined edges, does not hurt to palpate

Bruising: defined edges, pain w/ palpation

38
Q

Cafe-au-lait

A

birthmark

39
Q

Erythema Toxicum (Erythematous and symmetric )

A

rash, usually generalized.

40
Q

Cutis Marmorata

A

Blue red mottling, means the baby is cold.

If they do not go away with warmth, can be a sign of Downs

41
Q

Physiological Jaundice

A

yellowing of the skin >3 - 4 days after birth.

<3 - 4 days is concerning

42
Q

Carotenemia

A

Orange skin due to an over ingestion of vit. A (orange foods: carrots, squash, sweet potato, oranges)

43
Q

Stork bite, Red skin between the eyes or at the base of the neck

A

nevus simplex

44
Q

What are 3 physiological changes that occur in adolescents?

A

1- increase secretions from apocrine glands = body odor
2- increase in subcutaneous fat deposits
3- Appearance of secondary sex characteristics (breast tissue, pubic & axillary hair)

45
Q

Where is there increased pigmentation during pregnancy?

A

face, nipples, vulva, abdomen

46
Q

“mask of pregnancy”

brown patches appear on the face. May go away in a few months after the baby is born (sunscreen)

A

Chloasma

47
Q

Striae Gravidarum

A

Stretch marks during pregnancy (50% get them)

48
Q

A common, small, soft, benign skin tag. Usually develops in areas of friction.
Common in pregnant, elderly, or obese

A

Acrochordons (acro-cro-don)

49
Q

Spider angiomas

A

swollen blood vessels found slightly beneath the skin surface, often containing a central red spot and reddish extensions which radiate outwards like a spider’s web.

50
Q

Senile Lentigines

A

Liver spots, small, flat, brown macules, hyperpigmentation from sun exposure

51
Q

seborrheic keratosis

A

Raised, thickened areas of pigmentation. They look crusted, scaly, warty, dark, greasy, and “stuck on”

They develop mostly on the trunk but also on the face and hands and on both unexposed and sun-exposed areas.

They do not become cancerous!

52
Q

actinic (senile or solar) keratosis

A

Red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque.

They occur on sun-exposed surfaces and are directly related to sun exposure.

They are premalignant and may develop into squamous cell carcinoma!!

53
Q

Senile purpura

A

increased vascular fragility that leads to easy bruising

54
Q

What causes hair to grey?

A

decreased number of melanocytes

55
Q

Sm. flat area of pigmentation (eg: freckle)

A

Macules

56
Q

sm. elevated are of pigmentation (eg: nevus)

A

Papules

57
Q

macules >1 cm (eg: birthmarks)

A

Patches

58
Q

papules coalesce to >1 cm (eg: psoriasis)

A

Plaques

59
Q

Wheals

A

red, ichy, slightly raised (eg: mosquito bite, poison oak)

60
Q

Hives. coalesced wheals

A

Urticaria

61
Q

Vesicles

A

elevated blister < 1 cm (herpes zoster- shingles, varicella)

62
Q

What is a secondary skin lesion?

A

it is the result from a change over time in a primary lesion

63
Q

Ulcer

A

deep depression into dermis

64
Q

Excoriation

A

self-inflicted usually from scratching

65
Q

Lichenification

A

Prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules
looks like surface of moss (or lichen).

66
Q

Candidiasis (intertrigo)

A

yeast infection

67
Q

Rubeola

A

(measles) rash starts behind the ears and spreads to the rest of the body
Koplik spots in the mouth

68
Q

Koplik spots

A

clustered, white lesions on the buccal mucosa.

a symptom of measles

69
Q

Varicella

A

(chicken pox) sm. vesicles on trunk, spreads to body (not palms or soles), significant pruritus

70
Q

How does the skin react to a common allergic drug reaction?

A

generalized, bilateral rash

71
Q

Manifestation of Herpes simplex

A

(cold sores) tight vesicles emerge, followed by pustules and many shallow, painful ulcers.
Common location is upper lip, in oral mucosa and tongue.

72
Q

Manifestation of herpes zoster

A

Small, grouped vesicles emerge along route of cutaneous sensory nerve, then pustules, then crusts. Painful.

73
Q

Manifestation of Lyme Disease

A

Bull’s eye rash: The rash radiates from the site of the tick bite (5 cm or larger) with some central clearing

74
Q

Basal cell carcinoma

A

most common type of skin cancer, slow-growing, red ulcer with pearly borders

75
Q

Squamous cell carcinoma

A

erythematous scaly patch, fast growing

76
Q

Malignant Melanoma

A

lesions often dark, but can be any color; often with irregular borders.
Can be lethal

77
Q

What are the manifestations of dehydration?

A
  • dry mucosa membrane
  • cracked lips
  • Tongue fissure
  • poor turgor
  • bad breath
  • low urine output (oliguria)
  • Dizziness upon standing (orthostatic hypotension)
78
Q

Toxic Alopecia

A

hair loss due to severe illness or use of chemotherapy

79
Q

Kaposi sarcoma

A

common vascular cancer in HIV-infected persons. Considered an AIDS-defining illness.

multiple patch-stage early lesions are faint pink on the temple and beard area.

80
Q

Hirsutism

A

Excess body hair. In females this forms a male pattern on the face and chest and indicates endocrine abnormalities

Nursing Health Assessment (16 decks)

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