Assessment of Hair, Skin, Nails, and Head-to-Toe Review

Comprehensive vocabulary flashcards covering skin assessment, wound staging, respiratory sounds, cranial nerves, and physical examination findings based on lecture notes.

Perfusion

The passage of blood, a blood substitute, or other fluid through the blood vessels or other natural channels in an organ or tissue.

Gas Exchange

The physical process by which gases move passively by diffusion across the surface.

Tactile sensory perception

The brain's ability to understand (perceive) information coming from the skin, particularly the skin on the hands.

Stage 1 Wound

Intact skin with non-blanchable redness, usually over a bony prominence; the area can be painful, firm, soft, warm, or cooler compared to other tissue.

Stage 2 Wound

Partial skin loss involving the dermis, presenting as a shiny or dry shallow open ulcer with a pink wound bed without sloughing or bruising; may also be an intact or ruptured serum-filled blister.

Stage 3 Wound

Full-thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed; slough may be present.

Stage 4 Wound

Full-thickness tissue loss with exposed bone, tendon, or muscle; sloughing or eschar may be present, often including undermining and tunneling.

Unstageable Wound

Full-thickness tissue loss in which the base of the wound is covered in slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black).

Deep Tissue Pressure Injury

A localized area of maroon or purple discoloration of intact skin or a blood-filled blister caused by damage to underlying soft tissue from pressure or shear.

Macule

A small, flat spot on the skin.

Patch

A large, flat spot on the skin.

Papule

A small, solid bump on the skin.

Plaque

A large, raised area on the skin.

Nodule

A hard, deeper lump ($5\,\text{cm}$ or less) often referred to as a knot.

Wheal

A raised, itchy swelling often referred to as a welt or hives.

Vesicle

A very small blister containing clear fluid.

Bulla

A big blister containing clear fluid.

Pustule

A bump filled with pus.

Cyst

A sac-like lump filled with fluid.

Scale

Flaky skin resembling fish scales.

Crust

Dried blood or fluid appearing as a scab.

Fissure

A crack in the skin.

Erosion

Shallow skin loss.

Keloid

A thick, raised scar.

Lichenification

Thick skin resulting from repeated scratching.

Asymmetry (ABCDE Rule)

A warning sign of melanoma where one half of the mole does not match the other.

Diameter (ABCDE Rule)

A warning sign of melanoma where the lesion is larger than $6\,\text{mm}$ (about a pencil eraser).

Petechiae

Tiny red or purple pinpoint dots representing very small bleeding under the skin.

Purpura

Purple spots larger than petechiae caused by bleeding under the skin.

Ecchymosis

A large purple or blue area commonly known as a bruise.

Cherry Angioma

A small, bright red, round, and raised benign blood-vessel growth.

Jaundice

Yellowing of the skin, sclera, or oral mucosa caused by increased bilirubin.

Cyanosis

A bluish or gray skin color resulting from decreased oxygenation.

Clubbing

Rounded, bulging fingertips where the nail base angle is greater than $180^\circ$, caused by chronic low oxygen.

Spoon Nails (kobnychio)

Nails that curve inward like a spoon, often associated with iron deficiency anemia.

Delayed Capillary Refill

A finding where color takes $> 2\,\text{seconds}$ to return, indicating poor peripheral circulation.

Good Skin Turgor

The skin springs back quickly after being pinched, indicating adequate hydration.

Tumor (Physical Finding)

A lump or bump measuring $6\,\text{cm}$ or more.

Aura

Visual disturbances, such as flashing lights or zig-zag lines, that can occur before or during a migraine.

Consensual response

The phenomenon where both pupils constrict together when light is shined into only one eye.

Rhonchi

Low-pitched, course snoring sounds heard during inhalation, usually caused by mucus in larger airways.

Wheezing

High-pitched, musical sounds usually heard during expiration, caused by narrowed airways.

Crackles

High-pitched popping and crackling sounds heard during respiration, often caused by fluid in small airways.

Stridor

A high-pitched squeaking sound caused by an upper airway obstruction.

Bradypnea

Slow breathing characterized by less than $8\,\text{breaths/min}$.

Tachypnea

Fast breathing characterized by more than $30\,\text{breaths/min}$.

Hemoptysis

The presence of blood when coughing.

Subjective Data

Information provided by the patient that cannot be directly measured, such as "I feel anxious."

Objective Data

What the nurse observes, such as crying, poor eye contact, or pacing.

Romberg Test

An assessment where the patient stands with feet together and eyes closed; slight swaying is normal, but losing balance is abnormal.

PERRLA

An acronym for Pupils Equal, Round, Reactive to Light and Accommodation; primarily associated with Cranial Nerve III.

Cranial Nerve I (Olfactory)

The nerve responsible for the sense of smell.

Cranial Nerve II (Optic)

The nerve responsible for vision and visual acuity (tested by Snellen Chart).

Cranial Nerve V (Trigeminal)

The nerve responsible for facial sensation and chewing.

Cranial Nerve VII (Facial)

The nerve responsible for facial expressions (tested by smiling/frowning) and taste.

Cranial Nerve VIII (Vestibulocochlear)

The nerve responsible for hearing and balance (tested by the whisper test).

Physiological

•Developmental

•Lifestyle

•Environmental

factors that influence the adequacy of circulation, ventilation, perfusion, and transport of respiratory gases to the tissues:

MATH 1. Rounding to the Nearest Whole Number

Look at the first number after the decimal:

0–4 → round DOWN
5–9 → round UP

Examples: 6.2 → 6

• 6.4 → 6

• 6.5 → 7

• 6.8 → 7

• 12.9 → 13

Memory: “5 or more, raise the score!”

2. mcg ↔ mg 1 mg = 1,000 mcg

mg → mcg = × 1,000

Example:
2 mg × 1,000 = 2,000 mcg

mcg → mg = ÷ 1,000

Example:
500 mcg ÷ 1,000 = 0.5 mg

Easy Memory Trick

Small → Big = DIVIDE
mcg → mg = ÷ 1,000

Big → Small = MULTIPLY
mg → mcg = × 1,000

Example:
2 mg × 1,000 = 2,000 mcg

mcg → mg = ÷ 1,000

Example:
500 mcg ÷ 1,000 = 0.5 mg

Easy Memory Trick

Small → Big = DIVIDE
mcg → mg = ÷ 1,000

Big → Small = MULTIPLY
mg → mcg = × 1,000

3. Percentages

Turn the percentage into a decimal:

30% = 0.30

Then multiply.

Example

Patient can pay for 30% of 90 tablets.

90 × 0.30 = 27 tablets

✅ Answer: 27 tablets

If the question asks how many are left to pick up later:

90 − 27 = 63 tablets

✅ Answer: 63 tablets

🧠 Remember

“OF means MULTIPLY.”

30% OF 90
→ 0.30 × 90
→ 27