Skin, Hair, and Nails

describe the stages of pressure injuries

stage I 1: non blanchable erythema, skin is not broken

stage II 2: partial thickness skin loss

stage III 3: full thickness skin loss

stage IV 4: full thickness skin/tissue loss (can see bone, muscles, tendons)

unstageable: can’t determine stage cause its covered in something usually black aschar

how does a nurse determine pressure injury risk

braden scale

define the characteristics of suspicious lesions

ABCDE

Asymmetry

Border

Color

Diameter

Elevated

explain the skin color changes that can occur

pallor: caused by anemia, shock, vasoconstriction

• light skin: generalized pallor

• dark skin: yellow, brown, grey

cyanosis: low oxygen levels

• light skin: dusky blue

• dark skin: dull, only severe cyanosis can be detected in dark skin. check conjunctiva, oral mucosa, and nail beds

erythema: can be inflammation, fever, blushing, capillary stasis

• light skin: red, bright pink,

• dark skin: can be purpleish, use palpation

jaundice: caused by increased bilirubin

• light skin: yellow in sclera, hard palate, mucus membranes

• dark skin: best noted in junction of hard and soft palate

describe the different types of skin lesions

• macule, patch

• papule, plaque

• wheal/hive

• nodule, cyst, tumor

• vesicle, pustule

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a. Burrow

b. Comedone

c. Macule

d. Papilloma

e. papule

f. petechiae and purpura

g. plaque

h. pustule

i. scale

j. telagiectasia

k. vesicle l. weal