HEALTH ASSESSMENT RLE SNHS Assessment

Paleness of the skin due to inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation.

Pallor

• For dark-skinned clients, it would usually characterized by the absence of underlying red tonesin the skin and maybe most readily seen in the?

Buccal mucosa

In brownskinned clients, pallor may appear as _____ In black-skinned clients, the skin may appear _____. Pallor in all people is usually most evident in areas with the least pigmentation such as conjunctiva, oral mucous membrane, nail beds, palms of the hands, and soles of the feet.

Yellowish brown tinge

Ashen gray

Bluish tinge of the skin due to reduced oxygenation.

Cyanosis

Yellowish tinge of the skin and sclera.

Jaundice

Redness of the skin

Erythema

Integuments in the body for assessment?

Skin, hair, scalp, and nails.

The examination begins with a generalized inspection

using a good source of lighting, preferably?

Indirect natural daylight

Inspection of the skin involves 2 types of IPPA?

Inspection and Palpation

In some instance, the nurse may also need to use _____ to detect unusual skin odors

olfactory sense

_____ frequently related to poor hygiene?

Pungent body odoris

Excessive Perspiration

Hyperhydrosis

foul-smelling perspiration

Bromihydrosis

The skin is composed of three layers

Epidermis

Dermis

Hypodermis (Subcutaneous layer)

Hair consists of layers of _____ found overmuch of the body except the lips, nipples, soles of feet, palm of hands, vagina, and penis

Keratinized layers

Hair consists of layers of keratinized cells found found over much of the body except for the?

lips, nipples, soles of the feet, palms of the hands, vagina, and penis.

The nails, located on the distal phalanges of fingers and toes, are hard,transparent plates of _____ that grow from a root underneath the skin fold called the cuticle.

keratinized epidermal cells

Equipment need for assessmt of Skin, nails, hair, and scalp?

• Adequate lighting

• Comfortable room temperature

• Gloves

• Penlight

• Magnifying glass

• Centimeter ruler

Subjective Data: Focus Questions

• Skin rashes, lesions, itching, dryness, oiliness, bruising

• Changes in skin color, lesions, bruising

• Scalp lesions, itching, and infections?

• History of skin disorder?

• Surgical excision of skin lesions?

• Changes in texture, condition, and amount of hair?

• Changes in condition of nails and cuticles

• Skin, hair, and nail care habits; bathing patterns; soaps and lotion used?

• Shampoo, hair spray, coloring, nail enamel used?

• Amount of sun/tanning exposure (types of oils and lotions used)?

• Exposure to chemicals?

Non - palpable lesions?

Macule

Flat and colored (e.g.Freckle, petechia)

Macule

3 palpable lesions?

• Primary lesions

• Secondary lesions

• Vascular lesions

Elevated and filled with fluid (e.g. Blister)

Bulla / vesicle

Elevated and firm, has dimension of depth (E.g. Lipoma)

Nodule / Tumor

Elevated and filled with pus (e.g. Acne)

Pustule

Elevated and superficial (e.g. Mole

Papule

Encapsulated, filled with fluid orsemisolid mass (e.g. Epidermoid cyst)

Cyst

Localized edema (e.g. Insect bite)

Wheal

Primary skin lesions are:

• Bulla / vesicle

• Nodule / tumor

• pustule

• papule

• cyst

• wheal

What are the Secondary lesions?

• Ulcer

• Crust

• Scale

• Atrophy

• Lichenification

• Keloid

Skin surface loss, often bleeds?

Ulcer

Dried pus or blood

Crust

Thin, flaky skin?

Scale

Thin, shiny taut skin?

Atrophy

Thickened, roughened skin

Lichenification

Hypertrophied scar

Keloid

What are the vascular angiomas?

• Cherry angioma

• Spider angioma

• Petechiae

• spider vein

• ecchymosis

• hematoma

Ruby red; flat or raised

Cherry angioma

Bright red with radiating legs, pullulating seen on center of lesion,

or legs, or arms, and upper trunk, blanches when pressure is applied to center.

Spider angioma

Round red or purple macules

Petechiae

Bluish; may have radiating legs;seen mostly on legs

Spider veins

Round or irregular macular lesion; larger than petechia; color varies

and changes black, yellow, and green

Ecchymosis

Localized collection of blood creating an elevated ecchymosis;

associated with trauma

Hematoma

Nails are inspected for?

• Nail plate

• Shape

• Angle between the nail

• nail bed

• nail texture

• nail bed color

• intactness of tissue around nails

Normal hair is resilient and evenly distributed. In people with severe protein deficiency _____, the hair color is faded and reddish or bleached, and the texture is course and dry.

Kwashiorkor

Some therapies cause _____ (hair loss), and some _____ can cause very thin and brittle hair.

Alopecia

Hyperthyroidism

increase

a increase in growth of facial hair in females

Hirsutism

_____ areas are seen in nutritional deficiencies. _____ hair in an African American child may indicate severe malnutrition

Patchy gray

Copper-red

We Inspect and palpate scalp for the following:

Symmetry and texture

Severe itching in the scalp may have a presence of?

Lice

What test is performed in the nail for capillary refill?

Blanch test

detached nail plate from nailbed) indicates infection or trauma

Onycholysis

inflamed tissues of surrounding nails- referred to as ingrown nail) indicates infection.

Paronychia

Hangnails

Pale and cyanotic nails are seen in hypoxia or anemia; yellow discoloration seen in fungal infections or psoriasis; (vertical lines) seen in trauma

Splinter Hemorrhage

presence of grooves or furrows, Beau’s lines(caused by injury of severe illness)

Beau’s Line

Spoon nail

180° or greater (this may becaused by a long-term lack of oxygen.

Clubbing

Pinch up skin on sternum or under clavicle, what is this called?

Skin turgor

Observe and palpate texture, temperature and skin moisture using the?

The back of the hand

For temperature: Compare the two feet and the two hands, using the?

back of the hand and the fingers

Rough, thick. Dry skin, extremely cool or warm, wet, oily. Cold skin is seen in shock, hypotension,

arterial insufficiency. Very warm skin is seen in what cases?

fever and hyperthyroidism

With the presence of both primary and secondary lesions there maybe a manifestatons of?

Skin cancer

This arise from normal skin owing to disease or irritations.

Primary skin lesions

This ) arise from changes in primary lesions.

Secondary lesions

This may be seen with increased venous pressure; aging, liver disease, or pregnancy. Skin cancer can

manifest as either primary or secondary lesions.

Vascular lesions

In dark skin: lighter colored palms, soles, nail beds, and lips; black/blue area are over lower lumbar

areaf reckle-like pigmentation of nail beds

Mongolian spots

In white/fair skin: Sun tanned areas, white patches

Vitiligo

In white/fair skin: Generalized pale yellow to pumpkin color

Jaundice