Comprehensive Health Assessment Exam 2 (Hair Skin Nails)

Comprehensive skin assessment is always done ___ ___ to hospital or facility

upon admission

Assessment techniques: (inspection) ___, variations of ___, and ___. (palpation) ___, ___, ___, ___, ___, ___.

(inspection) color, variations of pigment, and lesions. (palpation) texture, temperature, thickness, turgor, moisture, mobility.

Color awareness - take ___ into consideration with what you find. Color blindness - ___ to consider pt’s ___.

skin color; neglecting, skin color

Skin color should be ___; check ___ ___ for baseline color. Exception: ___ areas, ___ areas - paler, ___ ___ areas - hyperpigmentation

even; inner arms. vascular; covered; sun-exposed

Albinism - ___ condition causing ___/___ ___ of ____

genetic; partial/total; loss; melanin

Vitiligo (hypopigmentation) - ___ ___ on skin. Due to ___ disorder - ___ destroyed. Common with ___ skin.

white patches. autoimmune; melanocytes. darker.

Melasma (hyperpigmentation) - only on ___; associated with ___ changes; worsens with ___ ___. Common with ___.

face; hormonal; sun-exposure. pregnancy.

Hemosederin staining (hyperpigmentation) - due to chronic ___ ___. Happens in ___.

venous insufficiency. legs. (poor venous return from legs causes blood to pool and those stressed vessels leak RBC and iron into surrounding tissue)

Striae (___ ___) - seen in areas of ___ ___. Common in ___ and ___. Over time they ___ or appear ___ colored. Dark skin - ___ ___ color. Light skin - ___/___ color.

stretch marks; rapid growth. pregnancy; obesity. fade; silvery. light brown. pink/red.

(Cyanosis) Light skin - ___-___ color. Dark skin - ___-___ color.

grayish-blue; nail beds, earlobes, lips, mucous membrane, palms and soles. ashen-grey; eye, nail beds, mucous membrane.

(Ecchymosis or ___) Light skin - ___, ___, ___, ___. Dark skin - deeper ___/___ tone; more ___ to see.

red, purple, yellow, green. blue/black; difficult

(Erythema or ___) Light skin - ___ tone. Dark skin - deeper ___ tone.

reddish. brown/purple.

Cellulitis - ___ of skin (increased ___/___)

infection; temp/tenderness

Jaundice - excess ____ by ____/____. Light skin - ___; ___/___, ___, ___ ___, ___. Dark skin - ___-___; ___/___, ___, ___, ___.

bilirubin, liver/gallbladder. yellow; sclera/conjunctivae, fingernail, oral mucosa, palm. yellow-green; sclera/conjunctivae, oral mucosa, palm, soles.

Petechiae - ___, ___ spots due to broken ___. Light skin - ___/___. Dark skin - ___/___; ___ to see.

tiny, flat (look like pin-points), capillaries. red/purple. purple/brown, difficult.

(Rash) Light skin - ___ and ___. Dark skin - may not be ___ but can be ___.

visible, palpable. visible, palpable.

Urticaria/Hives/Wheals - ____ to food, meds, environment. Usually ___. Treated with ___.

allergy. acute. antihistamine.

Nevi or ___ - ___ in color, can be raised (___) or flat (___); less than ___ mm.

moles. uniform. papule, macule; 5

Possible Melanoma - use acronym (___). Melanoma is often ___ common and diagnosed ___ in dark skin.

ABCDEF. less, later.

Basal Cell Carcinoma (___ common) - shiny/___ in color; ___ or ___ in shape; ____ center; ___ in growth.

most; pearly; papule or nodule; umbilicate; slow.

Squamous Cell Carcinoma (___ most common) - ____ lesions with ___ and ___, ___ in growth

2nd; hyperkeratotic (build-up of keratin), crusting, ulceration; agressive. (more common in immunosupressed or transplant pts.

Palpation of temp - on skin bilaterally using ___ hand. Fingertips and toes will slightly ___ (normal variation). Abnormal variations: hypothermia - ___ skin; hyperthermia - ___ skin.

dorsal. cooler. cold. hot.

Texture - skin is ___, ___, and ___. ___ on hand feel rough.

smooth, soft, intact. calluses.

Moisture - skin is ___. Abnormal variations: excessive ___; excessive ___ (diaphoresis) - abnormal is ____of strenuous activity.

dry. dry; moist, absence.

Thickness - varies by ___ and ___ of body. Increased thickness (___ ___) - causes areas of ___, ___, ___ skin in folds and creases of body (think maal)

age, area. Acanthosis Nigricans, dark, thick, velvety. (Notes: thickness decreases by age; skin is thinner on eyelids and thicker on palms/soles; Acanthosis Nigricans is not caused by poor hygiene)

Turgor - measure of ___. Check ___ or ___. Abnormal variations: ___ = dehydration; reduced mobility - ___, ___ ___, or ___.

hydration. forearm or clavicle. tenting; edema, excess scarring, scleroderma. (Note: check only clavicle for older adult)

Alopecia - ___ ___.

hair loss.

Alopecia Areata - multiple ___ of ___ ___ (___ disease).

patches, hair loss; inflammatory (Note: stress most likely cause)

Hirsutim - unwanted ___ ___ in ___. Caused by ___ and ___ ___.

hair growth, women. PCOS, hormonal changes.

(Scalp) Pediculosis - ___ or ___ (eggs); transferred by ___ to ___ ___. Seborrheic dermatitis - ___

lice or nits. person to person contact. dandruff.

(Nails Expected) Melanonychia - pigmented ___ lines on nail ___ border.

longitudinal, lateral.

(Nails Abnormal) Beau’s lines - ___ groove cause by trauma.

transverse. (Note: example is ripping off a press-on)

(Nails Abnormal) Koilonychia - ___/spoon nails. (anemia)

hollow.

(Nails Abnormal) Leukonychia - ___ spots on nail, caused by ___.

white, trauma.

(Nails Abnormal) Clubbing - nail bed angle greater than or equal to ___ (condition related: ___)

180; hypoxia.

(Nails Abnormal) Paronychia - infected ___; acute/chronic infection ___

hangnail; cuticle.

(Nails Abnormal) Onychomycosis - nail ___ (nail becomes ___, ___, ___)

fungus; thick, yellow, brittle.

(Nails Abnormal) Ingrown toenail - ___ nail grows into ___ (common)

lateral; skin

Newborn skin (redder - less ___ fat)

subcutaneous

(Newborn Expected) Acrocyanosis - cyanotic ___, ___, ___ after birth.

lips, nail beds, feet. (Note: disappears once warm)

(Newborn Expected) Jaundice - due to ___ and immature ___

bilirubin, liver. (Note: disappears in 1-2 weeks)

(Newborn Expected) Congenital dermal melanocytes - ___/___ patches over ___ and ___.

blue/green, back and buttock.

(Newborn Expected) Cafe au lait spots - light brown pigmented ___/___, associated with ___.

birthmark/patched, neurofibromatosis.

(Newborn Expected) Nevus simplex (___ ___) caused by telangiectasis (permanent ___ of blood vessels), small ___ or ___ spots.

stork bite, dilation, red, pink. (Notes: disappears by 5 years old.)

(Newborn Abnormal) Nevus flammeus (___ ___ ___) - large ___, ___ ___ color.

port wine stain, macule, blue purple. (Note: does not disappear; also dilation of vessels)

Infantile Homangioma - slightly ___, ___ color

raised, red. (Note: like a strawberry, disappears by 5 years old)

Cavernous Hemongioma - red/blue mass of ___ ___.

blood vessels. (Note: often shrink or go away)

Newborn Milia - small ___, ___ color.

papules, white.

Erythema toxicum neonatorum - ___ ___.

baby acne.

Adolescent skin variations - ___/___.

acne/pustule.

(Older Adult Expected) skin hangs ___ and is ___. Seborrheic keratoses - benign ___ ___. Dermatosis Papulos Nigra (variant of seborrheic keratoses) - ___ in size, seen in ___ ___ people. Solar lentigo - ___ ___. Skin tags - benign, ___ ___

loosely, cooler. raised moles. smaller, African American. sun spots. fleshy, lesions.

Bruises - be aware if they are in ___ areas or various ___ of ___.

unexpected, stages, healing.

Skin tears - mainly in ___ adults, people with ___ ___, chronic ___ skin, ___ skin.

older, impaired mobility, dry, thin.

Stage 1 Pressure Injury - non ___, ___, skin ___.

blanchable, redness, intact.

Stage 2 Pressure Injury - ___ thickness loss, ___ loss, ___ ___ ulcer, no ___.

partial, skin, shallow open, slough (discharge).

Stage 3 Pressure Injury - ___ ___ visible, ___ thickness loss, ___/___/___ not visible, there is ___.

subcutaneous fat, full, bones/tendons/muscle, slough.

Stage 4 Pressure Injury - ___/___/___ exposed.

bones/tendons/muscle.

Kennedy Terminal Ulcer - ___ shaped (___/___), happens ___.

irregularly, pear/butterfly, suddenly.

Unstageable Pressure Injury - covered with ___ or ___.

slough, eschar (dark, firm scab tissue).

Deep Tissue Injury (DTI) - dark purple/maroon area on ___ skin.

intact