Hlth Assess test: skin + nails

nails

epidermal cell converted to hard plates of keratin

function of integumentary

sun + heat protection

prevents penetration

pain + heat perception

temp regulation

identification (skin color/melanin)

communication

wound repair

absorption + excretion

production of Vit D

do you have any medical problems?

caution: diabetes/ endocrine problems/ peri vascular disease/ cv disease

equipment for phys exam

adequate lighting

comfy room temp

Vitiligo

Complete absence of melanin pigment in patchy areas of white/light skin

more notable in darker skin

Skin Thickness

callus from pressure/friction of work/weight bearing

thin/shiny skin = arterial insufficiency

Edema

unilateral? Bilateral?

Generalized= anasarca (considered a central problem r/t heart/kidney failure)

Turgor

tenting vs non-tenting

skin on forearm or under clavicle; move easily when lifted and return quickly back to place à no longer on back of hand

use forearm + under clavicle!!!!!! NOT back of hands

Cyanosis (light skin)

dusky blue

conjunctiva, nail beds, lips

cyanosis

increased amounts of deoxygenated blood

cyanosis (dark skin)

ashen gray

lips + tongue

nails + conjuctiva

Pallor

decrease in hemoglobin content

pallor (light skin)

no rosy cheeks

face

pallor (dark skin)

ashen gray (black)

yellow brown (brown)

Erythema

increased amount of RBC or blood flow

Erythema (light skin)

redness

whole body

Erythema (dark skin)

hard to assess —> palpate

feel for warmth/ edema/ purple tinge

Jaundice

increased bilirubin in skin + sclera

Jaundice (light skin)

yellow staining

sclera/ eyes/ skin/ fingers

Jaundice (dark skin)

yellow staining

sclera/ hard palate/ palms

Skin Lesion Types

Primary —> from previous normal skin

Secondary—> change in prim lesion

Vascular —> bleeding/ aging/ circ conditions/ diabetes/ pregnancy/ hepatic disease

any skin lesion = abnormal (besides freckles/ birthmarks/ moles)

Types of primary lesions

macule

patch

papule

plaque

nodule

tumor

wheal

vesicle

bulla

pustule

cyst

Macule

less than 1cm

flat + circumscribed

color change!

freckles or flat mole

patch

more than 1cm

cafe au lait

chloasma

papule

less than 1cm

solid and elevated

circumscribed

wart

plaque

larger than 1cm

forms elevation

plateau / disk shaped

psoriasis (silver)

Nodule

larger than 1cm

solid + hard + elevated

fibroma or intradermal mole

Tumor

few cm

form or soft

deep in dermis (malignant or benign)

Lipoma/ hemangioma

Wheal

superficial (raised)

erythmatous/ irregular shape —> edema

mosquito bite OR allergy

Urticaria

hives

coalesce of wheal (extensive reaction)

itchy

Vesicle

up to cm

elevated + fluid filled

blister/ herpes zoster

Bulla

more than 1cm

fluid filled BUT easily ruptured

BIG blister

burns or contact dermatitis

Pustule

turbid fluid filled

circumscribed + elevated

acne

cyst

encapsulated fluid filled cavity (tense skin)

deep in dermis (subq)

ABCDE skin cancer

Asymmetry

Borde

Color

Diameter (more than 6mm)

Evolving

Secondary Lesion

scales

lichenification

crust

atrophy

erosion

fissure

ulcer

scar (cicatrix)

keloid

excoriation

Scale

dry or greasy compact flakes

silvery + white

Fissure

linear crack (goes into dermis)

abrupt edges

diabetics + athletes foot

erosion

superficial shallow scooped out depression

pressure injury or popped vesicle

Ulcer

depression into dermis

may bleed + irregular borders

pressure injury

Excoriation

superficial + self inflicted + pruritic

insect bites or scabies

scar

permanent fibrotic change

lichenification

from prolonged scratching

thick skin + forms pustules

eczema

keloid

excess scar tissue —> beyond site of injury

common in: black/latinos/asian

ecchymosis

bruise

superficial bleeding under skin

(dark skin = mouth conjuctiva)

purpura

hemorrhagic disease

produces petechiae + ecchymosis (at multiple sites)

seen in thrombocytopenia/ scurvy/ older age/ blood leaks

(petechia dark skin = oral mucosa + eyelids)

bruises day 1-2

blue/purple

bruises day 6

green

bruises day 8-9

yellow brown

bruise 1st appearance

red

hematoma

elevated ecchymosis from blood collection

cherry angioma

0.5 to 6 mm

dome shaped, benign, papule (cherry red)

compressible mass of blood vessels

Higher in over 30 yr on trunk

telangiectasis

vascular lesion

dilated blood vessels = flat patches uniform size

NO central vessel

spider angioma

branched dilated capillaries (form of telangiectasis)

looks like spider

venous star/venous spider

herpes simplex

grouped lesion

cluster

insect bites

individual + separate + distinct

discrete

poison ivy or hookworm

linear or serpiginous

forms line (snake shaped)

childhood exanthema

lesions merge = confluent

rash associated with viral illness

ringworm

annular

circular pattern

drug reaction + urticaria

polycyclic

targeted lesions

concentric circles (bull’s eye)

targetoid

measles

generalized scattered over the body

herpes ZOSTER

zosteriform

Linear along nerve root

NO cross midline

pitting nails

small depression in nails

psoriasis/ chronic dermatitis/ alopecia areata

beau’s lines

indentations across nails

previous traumas/ heart attack/ malnutrition

common area of pressure injury

back of head + ears

shoulders + elbows

butt + lower back

hips

inner knees

heels of feet

Braden Scale

used for pressure sores

categories: sensory percept/ moisture/ activity/ mobility/ nutrition/ friction

lower score = higher risk (0-4 in each category)

Stage 1 pressure injury

nonblanchable

redness over bony prominences

Stage 2 pressure injury

blister

into dermis + small erosion

Stage 3 pressure injury

able to see into subQ (fat)

NO bone

Stage 4 pressure injury

able to see muscle and bone

necrotic

priority concepts for nursing diagnosis

impaired skin/tissue integrity

self image

infection risk