Intro to health assessment exam 1 (Skin, Hair, Nails)
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136 Terms
what is the largest organ in the body
the skin
how many sqf does the skin cover in adults
20 square feet
how many layers does the skin have
two
what is the outer layer of the skin
epidermis
what are characteristics of the epidermis
Basal cell layer, Outer horny cell layer, contains dead keratinized cells., Skin color
what is the inner supportive layer
dermis
what are the characteristics of the dermis
Connective tissue/collagen, Elastic tissue
whats beneath the skin
subcutaneous layer
what does the subcutaneous layer contain
adipose (fat) tissue
What environmental influences does skin adapt to?
heat and cold
What do sebaceous glands produce?
sebum (oil)
Which skin glands are important for fluid balance and thermoregulation?
sweat glands
what are the type os two sweat glands?
Eccrine and apocrine
What is nail clubbing?
Abnormal rounding of the fingertips with increased nail curvature
Abnormal rounding/enlargement of the fingertips with increased nail curvature.
hypoxia
What clinical concern should nail clubbing prompt the nurse to consider?
Inadequate oxygen reaching body tissues
What are the three general properties of the skin
Waterproof, protective, and adaptive.
What does the skin's protective function include?
Protection from the environment and prevention of penetration
Which skin function allows a person to feel touch, pressure, pain, and temperature?
perception
Which skin function helps the body respond to heat and cold?
Temperature regulation.
what is the identification function of the skin
distinguishing features such as fingerprints
what is the communication function of the skin
visible changes such as blushing or pallor
What are other functions of skin
Wound repair, absorption and excretion, and production of vitamin D
what is lanugo
Fine, soft hair on a newborn's body, an expected newborn finding.
What is vernix caseosa?
A white, creamy protective coating on a newborn's skin
Why are newborns vulnerable to heat loss?
Their temperature regulation mechanisms are immature
Which type of sweat gland is associated with cooling the body?
eccrine glands
A pregnant client develops a dark vertical line down the center of the abdomen. What is this called?
Linea negra
A pregnant client develops dark patches on the face, sometimes called the “mask of pregnancy.” What is this called?
Chloasma
A pregnant client develops linear stretch marks on the abdomen. What is this called?
striae gravidarum
What does skin atrophy mean in an aging adult?
thinning of the skin, making it fragile
What does loss of skin elasticity mean?
Reduced ability of skin to return to its original shape after stretching
what is senile purpura
Purple bruiselike patches from fragile blood vessels in older adults.
what is melanoma
a type of skin cancer
Can melanoma occur in patients with any skin tone?
yes, a nurse should always assess the pt despite skin tone
A patient develops a raised scar that grows beyond the original piercing site, what could that indicate
keloid
what is Hypopigmentation
an area with less pigmentation
what is Hyperpigmentation
an area with excess pigmentation
What is pseudofolliculitis?
Inflamed bumps caused by ingrown hairs
What is melasma
Patchy darkening of the skin, commonly on the face
What does SLE stand for
Systemic lupus erythematosus
what skin finding may be associated with SLE
A butterfly-shaped malar rash on the cheeks and nose
What is subjective data in a skin assessment?
what the patient tells you
How does perspiration generally change with age, according to the slide?
it decreases
A client says, “My hair has been falling out.” Subjective or objective?
subjective
The nurse observes patchy hair loss during inspection. Subjective or objective?
objective
What skin-color changes should the nurse ask about in a newborn?
physiological jaundice and cyanosis
What does jaundice look like?
Yellow discoloration of the skin and eyes.
What does cyanosis look like?
Bluish discoloration.
What is the important timing distinction for newborn jaundice?
Jaundice in the first 24 hours requires quick evaluation.
What TWO questions are essential when assessing a child's burns or bruises?
where is the injury and how did it happen
What common skin changes may occur during adolescence?
pimples and black heads
Are pimples and blackheads common during adolescence?
yes, but if painful or severe they need to be assessed
What two medical conditions are specifically listed in the older-adult skin history?
Diabetes and peripheral vascular disease (PVD).
Give an example of an emotional influence on skin.
Embarrassment= blushing, anxiety= sweating.
Give an example of an environmental influence on skin.
Cold surroundings= cooler skin, heat= increased sweating.
What should the nurse do before attributing a skin finding to an external variable?
Assess the client and consider other possible explanations
When does the nurse assess the skin during a complete physical examination?
throughout the entire examination
What should the nurse assess first when examining a body area?
the skin
What are intertriginous areas?
Skinfolds, such as under the breasts, abdomen, and groin.
Why must the nurse separate and inspect skinfolds?
warmth and moisture could cause irritation or infection
What is a regional examination?
is an assessment focused on a particular body area or concern
Why should the nurse assess the skin as one entity?
To identify the overall distribution pattern of skin findings
Which assessment techniques are used in a regional skin examination?
inspection and palpation
what does pallor mean
pale skin
What does erythema mean?
red skin
What does transient mean when describing a skin-color change?
temporary
What does pathology mean?
disease or abnormal condition
Which part of the hands should the nurse use to assess skin temperature?
back of the hands
What is the expected skin-temperature finding?
warm and equal bilaterally
What should the nurse do if one foot is much cooler than the other?
assess further
wat does Moisture mean
It refers to how dry or moist the skin feels.
whats diaphoresis
excessive sweating
whats dehydration
lack of body water
Does dry skin alone confirm dehydration?
no, the nurse has to assess further
what is skin texture
how the skins surface feels
What does the nurse assess when checking skin thickness?
whether the skin is thick or thin
what is edema
swelling caused by fluid in the tissue
what does mobility mean
how easily the skin moves when the nurse lifts it
what does turgor mean
how the skin returns to its usual position after being lifted and released.
What bruising patterns should raise concern about possible physical abuse?
Multiple bruises at different healing stages or multiple bruises above the knee or elbow
what is the antecubital fossa
the inside of the elbow
Where might needle marks or tracks be visible?
Antecubital fossae, forearms, or other veins.
what does location mean in a lesion
WHERE a lesion is.
what does distribution mean in a lesion
HOW lesions are spread across the body.
What four characteristics does the nurse assess during hair inspection and palpation?
color, texture, distribution and lesions
How does the nurse assess capillary refill?
Press the nail bed until it blanches, release, and observe how quickly color returns.
What is the expected capillary refill time?
two seconds or less
what dow e use the ABCDE rule for
for skin lesions
what does A in ABCDE rule in lesions mean
Asymmetry
what does B in ABCDE rule in lesions mean
Border
what does C in ABCDE rule in lesions mean
Color
what does D in ABCDE rule in lesions mean
Diameter
what does E in ABCDE rule in lesions mean
Elevation and Enlargement
A newborn has a flat, blue-gray patch on the lower back. What is it?
Mongolian spots
A baby has a flat, light-brown birthmark. What is it called?
Cafe au lait spot
what does Acrocyanosis mean
bluish discoloration of the hands and feet
An older adult has flat, brown age spots on the backs of the hands. What are they called?
Lentigines
An older adult has a small, soft growth hanging from the skin near the neck. What is it?
Skin tag
What does annular lesion mean?
ring shaped