Skin, nails, and hair assessment Flashcards
What is the largest organ and sensory organ
the skin
What keeps the body in homeostasis
the skin
what are the functions of the skin (6)
protection, sensation, regulation, secretion, excretion, vitamin D formation
What does the skin protect against
microorganisms, physical trauma, ultraviolet radiation, dehydration
What does skin do to a person’s appearance
it provides identity
How many layers is the skin composed of
epidermis, dermis, subcutaneous tissue
What is the epidermis
the outer layer of the skin, composed of 4 distinct layers
What is the dermis
the inner layer of the skin
What is subcutaneous tissue
loose connective tissue
Where are sebaceous glands not present
soles and palms
What are sebaceous glands attached to
hair follicles
What does sebum do
waterproofs the hair and skin
Pruritis
itching
Maceration
softening of the skin from prolonged moisture (raisin fingers)
Excoriation
loss of superficial layers of the skin
Abrasion
rubbing away of the epidermal layer of the skin
Pressure injuries
lesions caused by tissue compression and inadequate perfusion
Acne
inflammation of sebaceous glands
What are skin risk factors (7)
dampness, dehydration, nutritional status, insufficient circulation, skin diseases, jaundice, lifestyle/personal choices
What subjective data is needed (4)
HPI questions, health history, family history, lifestyle/health practices
What to inspect during skin assessment
color, mucous membranes, tongue, conjunctiva, edema, lesions
What do inspect/palpate for hair and scalp
color, texture, distribution, mobility, tenderness
What is the Braden Scale Assessment tool used for
to predict the pressure sore risk
What does a lower score on the Braden Scale Assessment mean
a greater possibility of developing a pressure ulcer
What areas are at a greatest risk for pressure ulcer
coccyx, heels, elbows, occiput (back of head)
What are the categories of the Braden Scale Assessment (6)
sensory perception, moisture, activity, mobility, nutrition, friction and shear
What development is important for infants
they have fragile skin
What development is important for children
they are more prone to injury and infection, they need help with cleaning
What development is important for adolescents
they have growing sebaceous glands, increasing sweat
What development is important for older adults (8)
thinning epidermis causing bruises, thin/translucent skin due to loss of elasticity, perspiration decreases due to a decrease in sweat gland activity, brown spots caused by decreased melanin, tenting, dry and scaly skin due to a decrease in production of sebum, hair is thin/dry, thick/brittle nails
ABCDE for melanomas
A - asymmetry
B- irregular borders (ragged, notched, blurred)
C - color change or variation
D - diameter
E - elevation or enlargement
Describe skin lesions (10)
skin, shape/pattern, color, distribution, texture, surface relationship, exudate, tenderness, pain, itching
Milia
white raised on the nose, chin, and forehead of newborns
What can be both a normal and abnormal finding (3)
nevi (moles), freckles, and birthmarks
Striae
stretch marks
Macule
flat, brown, less than 1 cm, non-palpable
Papule
elevated, palpable, solid mass
Vesicule
elevated and filled with serous fluid, less than 1 cm in diameter
Bulla
elevated and filled with serious fluid, greater than 1 cm in diameter
Cyst
fluid-filled or semisolid mass that is palpable
Pustule
palpable, elevated, filled with pus
Nodule
elevated, solid, firm
Wheal
elevated, superficial, edematous
Pallor
pale skin
Cyanosis
blue skin
Erythema
reddened area
petechiae
tiny pinpoint spots
mottling
marbling on skin
