Health Assessment Exam 2

This covers all exam 2 lecture notes taken, whiteboard activities, and the practice exam.

Purposes of skin

protection, feeling, traps heat, vitamin D storage

Integrity

Intactness

Protein is good for

the skin

Present health history of SHN

chronic illnesses, changes in skin, hair, nails, medications taken, any allergens?

Past health history of SHN

skin diseases, infections, trauma, skin cancer

Family history of SHN

skin diseases, autoimmune diseases

Personal and psychosocial history of skin

skin hygiene, use of sunscreen, UV exposure, occupational exposure to chemicals

Excoriation

abrasion or scratch

For a skin assessment, you should

remove socks and shoes

How do we provide privacy and comfort while doing a SHN inspection?

provide drape and ensure warm temp of setting

SHN Assessment is

done upon admission

explain to patient and family you will check entire skin

provide privacy and comfort

hand hygiene, gloves if needed

ask for help to turn if needed

know facility policies

INSPECT skin for

color, variations of pigmentation, lesions

PALPATE skin for

texture, temperature, moisture, mobility, turgor, thickness

Inspection and palpation usually performed

simultaneously for SHN

Color blindness

neglecting to consider clients skin color, can lead to incorrect assessments

Color awareness

understanding and assessing clients skin color and possible variations in findings

Inspecting and describing skin color

natural light preferred to fluorescent light

check inner arm for baseline color(not much sunlight)

general color should be even

exceptions - cheeks, genetalia, upper chest, continuously covered areas may be paler

palms and soles are typically lighter in darker skinned individuals

areas of sun exposure may show darker pigmentation

expected ranges from whitish pink to olive to deep brown

Albinism is a form of

hypopigmentation

Albinism

genetic absence of melanocytes

Vitiligo

hypopigmentation, white patches on skin and can occur anywhere, due to autoimmune disorder, melanocytes destroyed, more common in darker skin, not physically harmful but may be psychologically distressing

Melasma

hyperpigmentation

usually only on face, known as mask of pregnancy, tends to fade after, more common in W, associated with hormonal changes and worsens with exposure to sunlight

Hemosedin staining

hyperpigmentation

due to chronic venous insufficiency, poor return from legs with back up of fluid and RBCs from caps into interstitial tissues

Risk factors for hemosedin

advanced age, obesity, previous blood clots, injuries, surgery to legs

Striae

commonly seen in obesity and pregnancy or area of rapid growth, non harmful, generally fade or appear more silvery colored over time

Cyanosis in lighter skin

grayish blue tone indicating low O2, best seen in nail beds, earlobes, lips, mucous membranes, palms, soles of feet

Cyanosis in darker skin

ashen grey, best seen in conductive of eye, oral mucosa membranes, nail beds

Bruising on lighter skin

dark red, purple, yellow, green, depending on age of bruise

Ecchymosis means

bruise, flat and nonblanchable

Different stages of multiple bruises could indicate

abuse

Bruise in darker skin

deeper bluish/black tone, more difficult to see unless color occurs in area of light pigmentation, compare to color around

Erythema means

redness

Erythema on lighter skin

reddish rone, if cellulitis, increased skin temp and tenderness(palpation), secondary to inflammation

Erythema on darker skin

deeper brown/purple, if due to cellulitis, increased temp(palpation) secondary to inflammation

Jaundice on lighter skin

yellowish color due to excess bilirubin, best seen in skin, sclera, fingernails, palms of hands, oral mucosa

Causes of jaundice

liver or gallbladder disease, med side effects

Jaundice on darker skin

yellowish green color, best seen in sclera, palms, soles

Petichiae on lighter skin

small reddish/purple pinpoint areas caused by broken capillaries

flat, not itchy, not rash

various causes, some benign and some serious

Petichiae on darker skin

more difficult to see

may be more evident in buccal mucosa or sclera

Urticaria/Hives/Wheals

usually due to allergy to food, med, environmental irritant, bug bite

usually acute

swollen, itchy area

can be treated by antihistamines

Wheal

elevated, irregularly shaped area of SQ edema, insect bite

Pigmented nevi

moles

expected 10-40 on sun exposed areas, above waist

less than 5mm

uniform in color

can be raised or flat

clearly defined border

need to be distinguished from malignant lesions

Moles vs Melanoma ABCDEF scale

A - asymmetry

B - border

C - color

D - diameter

E - evolving

F - feeling

A in ABCDEF

not round or oval?

B in ABCDEF

poorly defined or irregular borders

C in ABCDEF

uneven or variegated color

D in ABCDEF

is it greater than 6mm?

E in ABCDEF

changing, getting bigger, darker etc

F in ABCDEF

itching, burning, tingling etc

Melanoma in darker skin

less common, increased melanocytes help protect skin from sun damage, often diagnosed later on, black people are more likely to die from melanoma

Melanoma is

cancerous and metastasizes

Basal Cell Carcinoma

most common form of skin cancer

affects light skinned individuals between 40-80

locally invasive, can grow large but rarely metastasizes

more common in M

nodular pigmented lesions with depressed center and rolled borders and or central w ulceration in areas of sun or UV exposure

Squamous Cell Carcinoma

2nd most common skin cancer

invasive cancer on head, neck, from sun or UV exposure

most common in people over 40 with blue eyes and childhood freckling

M more commonly affected

Red, scaly patch w sharply demarcated border

lesion is soft, mobile, slightly elevated, and matures to central ulcer with surrounding redness

Palpation of the skin is done

on skin, never over clothes

bilaterally to compare L and R

use dorm of hands

shoulders to fingertips and mid thigh to toes

fingertips and toes may be slightly cooler

normal skin temp is warm

cold skin in environment could mean

hypothermia

cold skin in shock presents as

cool and clammy

Localized cold feet/hands could be a possible sign of

peripheral arterial disease

hot skin due to increased metabolic state could mean

fever, hyperthyroidism

hot skin in environment may mean

heat stroke

Localized areas of increased warmth could be

possible sign of inflammation/infection

How do you palpate skin?

grasp bilateral extremities with palms and gently palpate proximal to distal

What do you feel for palpating skin?

texture - should be smooth and soft, intact, even, calluses expected, elbows and knees rough and thickened

moisture - should be dry, not excessively dry, minimal oiliness, increased perspiration with temp, activity, anxiety

thickness - varies by age and area, thickest over palms and soles and eyelids

Diaphoresis

excessive moisture, abnormal in absence of strenuous activity

Possible causes of diaphoresis

hyperthermia, extreme anxiety, pain, shock, hyperthyroidism, hypoglycemia

Decreased skin thickness

can be seen in hyperthyroidism, arterial insufficiency, aging

skin also may be shiny and hairless on legs with advanced age and arterial insufficiency

Acanthoses Nigricans

Diabetes mellitus can cause collagen resulting from hyperglycemia

condition causes areas of dark, thick, velvety skin in body folds and creases and typically affects armpits, groin, neck, NOT due to poor hygiene

How to assess for turgor

pick up slightly pinch skin on forearm or under clavicle(older adult)

Do not check dorm of hand on older adult

Skin should be elastic and return immediately when raised - no tenting

Abnormal findings for turgor

tenting - dehydration or excess weight loss

reduced mobility - edema, excess scarring, scleroderma

Hair inspection

Scalp - smooth with no evidence of flaking, stalling, redness, open lesions, shiny and soft hair, texture may be fine or coarse, note quality and distribution of hair, possible abnormalities are brittle and dull

Alopecia

hair loss - autoimmune disorders, anemic conditions, nutritional deficiencies, radiation or antineoplastic treatments

male pattern baldness is genetic and hormonally influences

Alopecia areata

chronic inflammatory disease of hair follicles

unknown cause, believed to be autoimmune, metabolic or stress

multiple round patches of hair loss or no hair

poorly developed hair shaft breaks and grows back in 3-4 months, some total loss

Hair loss due to chemo

chemo attacks rapidly growing cells(hair)

Hirsutism

unwanted hair growth in W with increased in hair on face, body, pubic area

can be related to hormonal change

can also be related to PCOS

Pediculosis

head lice and nits, common in kids, spread thru person to person contact or shared clothing, small visible nits(eggs) at base of hair shaft, skin is red and excoriated

Sebhorric dermatitis

dandruff, in infants called cradle cap

red patches and greasy scales on scalp

can also occur on face, around nose, along eyebrows, upper chest

more common in lighter skin

treatment with anti fungal dandruff shampoo

Nail surface

should be smooth and flat and slightly curved downward at edges

palpated nail beds should be firm

nail beds pink

brown or yellowish on darker skin

Melanonychia

expected nail condition, pigmented longitudinal lines on nails

can occur on dark or light but more common in dark

seen in up to 90% darker skinned people

if lines are greater than 3 mm width and changing in a single nail, may be evaluated for melanoma

Beau’s Lines

transverse groove across nail

caused by trauma

start at base by cuticle and grows out

Koilionychia

spoon nails, may be congenital, may be caused by anemia or other medical conditions

Leukonychia

while, caused by trauma to nail

Clubbing

change in soft tissues cause straightening of natural curvature of nailed, angle of 180 or greater, associated with chronic hypoxia like in emphysema, congenital heart problems in kids

Paronychia

acute or chronic infection of cuticle

infected hangnail

painful inflammation at base of nail, abscess may form, moves along side of nails

exposure to moisture, nail biting are risk factors

Onychonycosis

fungus, usually toenails but occasionally fingernails

nail becomes thick, yellow, brittle

difficult to fully eraticate

can be treated with anti fungal med

Ingrown toenail

common, lateral nail grows into skin, usually great toe, caused by cutting nail too far down sides, shoes too tight, injury, redness, purulent drainage, pain

Newborns have

thinner, more permeable skin, so it is important to keep them warm

Apocrine sweat glands and sebaceous gland activity increases in

adolescents, resulting in oilier skin and acne

Newborn skin inspection

skin color depends on fat

preterm - redder, less SQ fat

neonate - red related to vasomotor inability, fades

dusky cyanotic lips, nail beds, feet immediately after bath that disappears once warmed called acrocyanosis

well oxygenated have pink tones

dark skinned have dark pink tone

Jaundice in newborns

appears in the 2nd to 5th day of life, half of all newborns, due to by products of hemoglobin breakdown and immature liver(bilirubin build up)

does not usually need treatment

disappears in 1-2 weeks

Congenital Dermal Melanocytosis

Mongolian blue spots

found in most newborn with darker skin

due to increased melanocytes, excessive melainin

irregular shape usually on back or buttocks

usually disappears 1-2 years
flat, nonpainful

may be confused for bruises

Cafe Au Lait Spots

large, round, oval

flat, pigmented

light brown in color

occasionally associated with neurofibromatosis

usually present at birth but can develop in first few years of life

Stork Bites

can be caused by telediectasis

can be caused by flat capillary hemangionma(bvs burst)

common vascular

small, red or pink spot seen on back of neck or eyelid

usually disappears by 5 years

Nevus Flammeus

port wine stain

large, macule

bluish, purple capillary areas

usually on face along 5th cranial nerve

usually does not disappear, often pink and becomes red or purple

laser treatment but not always effective

Infantile Hemangioma

strawberry hemangioma

slightly raised

red with sharp demarkation line

maybe 2-3 cm

usually disappear by 5 years

may require laser treatment

Cavernous Hemangioma

reddish blue mass of bvs(vascular)

may continue to grow until 10-15 months of age

should be assessed frequently but often shrink and go away

could affect eyesight or breathing

treatment is surgery, depending on location, symptoms, and bleeding

Milia

milk spots, small pustules on cheeks, nose, chin, forehead(disappear by 3rd week of life)

Rash - Erythematoxicum neonatorum

baby acne

common rash that lasts few days, gone within 2 weeks

self limiting

macules, papules, pustules

can appear anywhere except palms and soles

usually appears by 3rd and 4th day of life

Newborn hair

fine and soft

may have lanugo(silky body hair)

may be found anywhere by scalp, ears, shoulders, and back most common

Cradle Cap

expected, infantile seborrhic dermatitis

crusty, oily scales on scalp, may also be on ears, nose, groin

mothers hormone cause increased oil production in oil glands, disappears over time

Adolescent skin changes

texture becomes more adult like

increased perspiration and BO

increased sebaceous gland activity and skin oils

acne peaks at 16

blackheads - open

whiteheads - closed

Pustule

elevated, superficial, filled with purulent fluid, pus

Vesicle

filed with serous fluid, elevated, superficial, chicken pox