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Nursing 2910 > Skin, nails, and hair assessment > Flashcards

Skin, nails, and hair assessment Flashcards

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1
Q

What is the largest organ and sensory organ

A

the skin

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2
Q

What keeps the body in homeostasis

A

the skin

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3
Q

what are the functions of the skin (6)

A

protection, sensation, regulation, secretion, excretion, vitamin D formation

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4
Q

What does the skin protect against

A

microorganisms, physical trauma, ultraviolet radiation, dehydration

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5
Q

What does skin do to a person’s appearance

A

it provides identity

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6
Q

How many layers is the skin composed of

A

epidermis, dermis, subcutaneous tissue

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7
Q

What is the epidermis

A

the outer layer of the skin, composed of 4 distinct layers

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8
Q

What is the dermis

A

the inner layer of the skin

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9
Q

What is subcutaneous tissue

A

loose connective tissue

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10
Q

Where are sebaceous glands not present

A

soles and palms

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11
Q

What are sebaceous glands attached to

A

hair follicles

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12
Q

What does sebum do

A

waterproofs the hair and skin

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13
Q

Pruritis

A

itching

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14
Q

Maceration

A

softening of the skin from prolonged moisture (raisin fingers)

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15
Q

Excoriation

A

loss of superficial layers of the skin

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16
Q

Abrasion

A

rubbing away of the epidermal layer of the skin

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17
Q

Pressure injuries

A

lesions caused by tissue compression and inadequate perfusion

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18
Q

Acne

A

inflammation of sebaceous glands

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19
Q

What are skin risk factors (7)

A

dampness, dehydration, nutritional status, insufficient circulation, skin diseases, jaundice, lifestyle/personal choices

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20
Q

What subjective data is needed (4)

A

HPI questions, health history, family history, lifestyle/health practices

21
Q

What to inspect during skin assessment

A

color, mucous membranes, tongue, conjunctiva, edema, lesions

22
Q

What do inspect/palpate for hair and scalp

A

color, texture, distribution, mobility, tenderness

23
Q

What is the Braden Scale Assessment tool used for

A

to predict the pressure sore risk

24
Q

What does a lower score on the Braden Scale Assessment mean

A

a greater possibility of developing a pressure ulcer

25
Q

What areas are at a greatest risk for pressure ulcer

A

coccyx, heels, elbows, occiput (back of head)

26
Q

What are the categories of the Braden Scale Assessment (6)

A

sensory perception, moisture, activity, mobility, nutrition, friction and shear

27
Q

What development is important for infants

A

they have fragile skin

28
Q

What development is important for children

A

they are more prone to injury and infection, they need help with cleaning

29
Q

What development is important for adolescents

A

they have growing sebaceous glands, increasing sweat

30
Q

What development is important for older adults (8)

A

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

31
Q

ABCDE for melanomas

A

A - asymmetry
B- irregular borders (ragged, notched, blurred)
C - color change or variation
D - diameter
E - elevation or enlargement

32
Q

Describe skin lesions (10)

A

skin, shape/pattern, color, distribution, texture, surface relationship, exudate, tenderness, pain, itching

33
Q

Milia

A

white raised on the nose, chin, and forehead of newborns

34
Q

What can be both a normal and abnormal finding (3)

A

nevi (moles), freckles, and birthmarks

35
Q

Striae

A

stretch marks

36
Q

Macule

A

flat, brown, less than 1 cm, non-palpable

37
Q

Papule

A

elevated, palpable, solid mass

38
Q

Vesicule

A

elevated and filled with serous fluid, less than 1 cm in diameter

39
Q

Bulla

A

elevated and filled with serious fluid, greater than 1 cm in diameter

40
Q

Cyst

A

fluid-filled or semisolid mass that is palpable

41
Q

Pustule

A

palpable, elevated, filled with pus

42
Q

Nodule

A

elevated, solid, firm

43
Q

Wheal

A

elevated, superficial, edematous

44
Q

Pallor

A

pale skin

45
Q

Cyanosis

A

blue skin

46
Q

Erythema

A

reddened area

47
Q

petechiae

A

tiny pinpoint spots

48
Q

mottling

A

marbling on skin

Nursing 2910 (15 decks)

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