skin, hair, nails health assessment

does skin contribute to identity?

tattoos

skin color

acne

piercing

degree 1 burn

sun burn - light pink skin

2nd degree burn

sun poising, blisters

3rd degree burn

Full thickness damage through skin into nerves and muscles

ecchymosis

bruise

petechiae

a small red or purple spot caused by bleeding into the skin.

uticaria

hives

prurius

itchy

wheals

large lesions

clubbing of fingers

Enlargement of fingertips due to chronic hypoxia.

skin history of adults

past skin diseases

sun exposures

recent changes - warts or moles

sores

geriatric skins

thinning, dryness, wrinkles, and age spots due to natural aging processes

normal nevi

moles

dysplastic nevi

atypical moles that can develop into skin cancer

lots of small dots (on back)

melanoma moles

asymmetry

border

color

diameter

elevation/evolving

firm

growing progressively

ABCDEFG

skin assessment IPPA

inspection

- color, changes

vitiligo

loss of pigment in areas of the skin

micheal Jackson

Mongolian spots

bluish purple spots of pigmentation

Jaundice

yellow skin and sclera

cyanosis

blue skin, mucous membranes, conjunctiva, lips

pallor

pale conjunctiva

erythema

redness

hypoxia

lack of oxygen

inspection of the skin

intactness of skin, color, shape/position/size lesions, scars?

configuration of a rash

grouped

zosteriform

annular and arciform

linear

distribution of rash

plantar, facial, patchy, symmertrical, heat rashes

palpation of the skin

temperature

moisture

texture

turgor

edema

edema

puffy swelling of tissue from the accumulation of fluid

macule

flat, circumscribed, colored lesions

freckles

macular rash

flat and red, less than 1 cm in diameter

patch

large macule

flat, non-pliable, irregular shaped macule, more than 1 cm in diameter

papule

small, solid, raised lesion on surface of the skin

plaque

elevated, solid, superficial lesions

greater than 1 cm in diameter

larger papule

nodule

growth of abnormal tissue under skin

can also be in deeper tissue and organs

tumor

elevated and solid lesion

may or may not be clearly demarcated, deeper in dermis, greater than 2 cm in diameter

wheal

an area of the skin which is temporarily raised, typically reddened, and usually accompanied by itchy

welt, hive

allergy related

urticaria

allergic reaction of the skin characterized by the eruption of pale red, elevated patches called wheals or hives

vesicle

lesion that is fluid filled

aka pustule

bullae

cyst

large fluid filled lesion

pustule

elevated, superficial lesion, similar to a vesicle but filled with purulent fluid

acne

secondary lesions

erosion, excoriation, scale, crust

fissure, scar, keloid, ulcer, atrophy

erosion

loss of part of the epidermis, depressed, moist, glistening, follows rupture of a vesicle or bulla

excoriation

Skin sore or abrasion produced by scratching or scraping

scale

heaped-up keratinized cells, flaky skin, irregular, thick or thin, dry or oily, variation in size

crust

dried serum, blood, or purulent exudate slightly elevated, size varies, brown, red, black, tan or straw in color

fissure

an opening; a groove; a split

scar

A mark on the skin that is left after a cut or other wound has healed.

keloid

Thick scar resulting from excessive growth of fibrous tissue

atrophy

thinning of the skin surface and loss of skin markings, skin appears translucent and paper like

ulcer

open sore or lesion in the skin or mucous membrane

purpura

red-purple skin lesion due to blood in tissues from breaks in blood vessels

hematoma

a solid swelling of clotted blood within the tissues.

ecchymoses

larger blue or purplish patches on the skin (bruises)

spider angioma

-red center with radiating red legs

-up to 2 cm

-can be raised

venous star

bluish spider, linear or irregularly shaped; does not blanch with pressure

cherry angioma

mole like skin growth made up of small blood vessels or capillaries

skin breakdown

bedsore

pressure sore

dermal ulcer

decubitus

braden scale

assessment for risk for ulcer development

score 9-23

lower is a higher risk

hair assessment

scalp lesions, itching, infection, lice, texture of hair, changes, cleansing, coloring, perms

IPPA of hair

inspection and palpation

color, amount, texture, pattern of loss, lumps, masses, lesions, scaliness, hygiene

history of nails

changes in nails and cuticles

nail breaking and splitting

cuticle inflammation

IPPA nails

inspection and palpation

color - pink

note ridges, markings hematoma

inspection of nails

shape - check for clubbing

palpation of nails

hard

smooth, firm, pink

smooth, rounded

psoriasis, pitting, onycholysis