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

ABCDE of melanoma detectionAsymmetry, Border irregularity, Color, Diameter of more than 6mm, Evolution of lesion over time

ABCDE of melanoma detection

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

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. Hematomas are palpable lesions, and their colorations mimics that of ecchymoses

Hematoma

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 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

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

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 Vascular 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

Hyperpigmentation developed during pregnancy. Common to see on neonates

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

Pustule

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

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

The nurse is admitting a 79 year old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The patient may have been abused

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

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

d) Cystic acne

Pustular acne

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

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.

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

Cupping

The nurse is admitting a 75-year-old man with a 50-year history of smoking one pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is

Clubbing

All of the following skin lesions are popular except

Herpes zoster

A nurse observes a skin lesion with well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion?

Patch

When assessing hydration, the nurse will

pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal

A fair-skinned blonde, 18 year old woman is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching?

Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer.

A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface. Some have scabbed over. The nurse suspects which of the following infectious diseases?

Varicella

A 24 year old patient reports an itchy red rash under her breasts. Examination reveals large, reddened, moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions?

Satellite

A 22 year old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in.) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion?

Keloid

An 83 year old woman is undergoing a route physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation?

Thinning of the skin

A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion?

Pustule