Jensen: Chapter 11 - Hair, Skin, and Nails Assessment

ABCDE of melanoma detection

ABCDE of melanoma detection:

Asymmetry, Border irregularity, Color, Diameter of more than 6mm, Evolution of lesion over time

What is the largest organ of the body?

The Skin

Wound caused by shear force or friction against the skin, removing several layers and exposing the dermis

Abrasion

Can be a window to other body systems

The Skin

A contained accumulation of pus within a tissue

Abscess

Ragged wound that occurs when trauma forces the skin to separate from underlying structures

Avulsion

A fluid-filled bubble on the skin caused by friction, burning, or hypersensitivity

Blister

Finding in the nails that indicates chronic hypoxia (LOW O2)

Clubbing of the nails

A practice among Southeast Asians in which a coin or other object is rubbed across the skin in a specific manner to treat various health concerns

Coining

A cultural practice involving the placement of a cup on the skin surface, applying heat to form a vacuum

Cupping

Gray or blue skin color, indicating lack of oxygen

Cyanosis

Skin lesion that is distinct and walled-off and which contains fluid or semisolid material

Cyst

An atypical mole

Dysplastic nevus

Bruise or bruising

Ecchymosis

Redness

Erythema

Turning red, as with fever

Flushing

Collection of blood under the skin; usually results from blunt force trauma.

Hematoma

Hematomas are palpable lesions, and their colorations mimics that of ecchymoses (bruises)

Yellowish discoloration of the skin and conjunctiva caused by a buildup of bilirubin in the body

Jaundice

Accentuation of normal skin lines resembling tree bark, commonly caused by excessive scratching

Lichenification

A superficial or deep skin tear, often requiring suturing to heal correctly

Laceration

Flat, distinct, colored area of skin that is less than 10mm(1 cm) in diameter and does not include a change in skin texture or thickness

Macule

Red macular lesions distributed over the forehead, cheeks, and chin, resembling the pattern of a butterfly

Malar rash

Solid palpable lesion greater than 1 cm in diameter, often with some depth

Nodule

Paleness of the skin (due to anemia)

Pallor

Raised, defined lesion of any color, less than 1 cm in diameter

Papule

Small reddish to purple macules or papules that can develop anywhere on the body in response to physical trauma

Petechiae

Raised, defined lesion of color, greater than 1 cm in diameter

Plaque

An abnormal growth of tissue originating on a mucous membrane

Polyp

(that photo is a nasal polyp)

Loss of skin surface, extending into dermis, subcutaneous tissue, fascia, muscle, bone, or all of these

Pressure ulcer

People with no hair on their body often have which disease?

Peripheral Artery Disease

Overgrowth of scar tissue

Keloid

Reddened lesions that arise from previously normal skin and include maculae, papules, nodules, tumors, polyps, wheals, blisters, cysts, pustules, and abscesses. May be further described as nonelevated, elevated solid, or fluid filled.

Primary lesions

Flat and blue, or blue-gray in color. Hyperpigmentation developed during pregnancy. Common to see on neonates.

dermal melanocytosis

Formerly called "Mongolian spots"

Itching

Pruritus

Acute dehydration, cyanosis, or acute lacerations, acute trauma, burns are all requiring what kind of assessment

Urgent Assessment

Suspicious lesions or rash + fever are USUALLY

Not requiring an urgent assessment

Wound with greater depth than width, caused by a sharp object piercing the skin

Puncture wound

Red or purple skin discolorations that do not blanch when pressure is applied. They are caused by bleeding underneath the skin. Measures 0.3 to 1.0 cm

Purpura

Purulent fluid-filled raised lesion of any size

(purulent = consisting of pus)

Pustule (THINK PUS)

Redness of the skin, commonly as a result of inflammation

Rubor

Skin changes that appear following a primary lesion (ex: scar tissue, crusts from dried burn vesicles)

Secondary lesions

An examination of the skin that the patient himself or herself performs to identify potentially problematic lesions

Self-skin examination

A persistent pinch

Tenting

An abnormal growth of tissue, whether malignant or benign

Tumor

Skin's ability to change shape and return to normal (elasticity). Used to assess the status of fluid loss or dehydration in the body

Turgor

Precipitation of renal urea and nitrogen waste products through swear onto the skin (whitish coating noted with severe kidney failure)

Uremic frost

Fluid-filled lesion less than 1 cm in diameter

Vesicle

Skin condition characterized by areas of no pigmentation

Vitiligo

Raised, flesh-colored or reddened edematous papules or plaques, varying in size and shape.

Wheal

Classified as either serous (clear) or sanguineous (bloody)

Wound drainage

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale.

The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development.

Total score: 19-23 = no risk; 15-18 = mild risk; 13-14 = moderate risk; 10-12 = high risk; <9 = very high risk

When documenting that a patient has freckles, the appropriate term to use is

Macules

A patient with a zosteriform rash has a rash that

is distributed along a dermatome

(think of herpes zoster)

single lesion(s) in close proximity to larger lesion, as if "orbiting" ; cutaneous candidiasis

satellite distribution

clustered; herpes simplex

grouped distribution

distributed over large body area; psoriasis acbe vulgarisms, exfoliative dermatitis

generalized distribution

with enlargement or multiplication, begins to coalesce to form larger lesion; urticaria, tinea versicolor

confluent distribution

distributed widely across affected area without any pattern; drug reaction, rubella, rubeola

diffuse distribution

single, separated, well-defined borders; melanoma, wart

discrete distribution

A mother brings her 4 year old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. One examination the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

Scabies

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash?

Fluid-filled lesions less than 1 cm in diameter.