Skin, Hair, and Nails

Risk Facts for Pressure Injuries

Decreased mobility, decreased sensation, decreased blood flow, fecal or urinary incontinance, fractures or contractors, poor nutritional status or low albumin

Wheal

superficial, raised, reddened, pink, pale, red or white.

Nails

Shape, contour, consistency, color, capillary refill, sluggish

Second skin lesions

Result from change in primary lesion, debris on skin surface, scales

Inspect and palpate

Texture, thickness, edema, mobility and turgor

Assess lesions

color, location, size, elevation, number, texture, type, shape, pattern 

Physical exam

Separate areas such as breasts, abdomen, and groin and make sure to look between toes feet and nails. 

Cyst

Can be semi-solid or liquid, fluid-filled cavity, elevated

Actinic Keratosis

Flat, papule, older, fair skinned people, benign, squamous cancer

Seborrheic Keratosis

Brown, yellow, raised multiple on trunk, benign, older people. 

Inspect

Color baseline, note color change, look for birthmarks, moles, or frecs. 

Hair

Color, texture, lesions, distribution

Pustule

Filled with puss, elevated, ache, increased sebum production.

Petechia and Purpura

blood flows out of ves., discrete, flat, no blanche or pulse/ greater than 3mm, confluent patch, ecumosis.

Edema

Excessive fluid in interstitial spaces.

Where is edema found?

In feet, legs, and sacral areas.

What does edema feel like?

Tight, puffy, and swelling

Hair abnormal findings

Tinea capitis, alopecia areata, trichotillomania, pediculosis capltis, hisutism

Ecchymosis

Larger than 3mm, can be purple, blue, green, no blanching, bleeding disorders of traumas.

Crust

Blister busted, yellow, white, debris on skin. 

Pressure Injuries

Localized area of skin damage caused by prolonged pressure on the skin.

What are pressure injuries due to?

Friction, pressure, shearing, and moisture.