1 - skin, hair, nails

skin fxn:

• protection from environment

• prevents penetration

• perception

• temp regulation

• identification

• communication (blushing)

• wound repair

• absorption and excretion

• production of vit D

health history

• history of skin cancer

• birthmarks or tattoos

• allergies to topicals

• skin color changes

• non healing wounds or suspicious lesions

• itching, dryness, or pain

• how do you care for your skin

what might cause erythema

• fever

• inflammation

• emotional rxn

• polycythemia

• venous stasis

• carbon monoxide poisoning

what might cause jaundice

• hepatitis

• cirrhosis

• sickle cell

• transfusion

• hemolytic disease in newborn

• too much bilirubin

what might cause pallor

• high stress situations due to vasoconstriction

• cold

• cigs

• anemia

• shock

• arterial insufficiency

if PT has pallor from shock, assess for

• low BP

• rapid pulse

• oliguria

• apprehension

if PT has pallor from anemia assess for

• fatigue

• rapid pulse

• dizziness

• impaired mental fxn

what causes cyanosis

• dec. perfusion

• hypoxemia

• shock

• cardiac arrest

• heart failure

• COPD

• heart disease

if pt has cyanosis assess for

• trouble breathing

• lung/heart sounds

• low O2 sat

• vital signs

nails

• should be slightly curved or flat, smooth or rounded

• clean and groomed = adequate self care

• yellow - cig use

• blue = cyanosis

abnormal characteristics of lesions

ASYMMETRY

BORDER

COLOR

DIAMETER

ELEVATION

FUNNY LOOKING

reliable sites in dark skinned clients

under tongue, buccal mucosa, conjunctiva, sclera of eyes