Skin, hair, and nails assessment LAB 4

Skin Assessment 8 factors

CLIMATTTE-
Color, Lesions, Inflammation, Moisture, Appearance, Temperature, Texture, Turgor, Edema

pallor

paleness, usually face, mucous membranes, and bottom of feet

cyanosis

bluish discoloration of the skin
common around lips and nailbeds, due to hypoxia and lack of circulation

jaundice

common in the sclera of the eye and skin, caused by liver dysfunction

erythema

redness, due to immune response (injury temperature)

diaphoresis

sweating
response to temperature or disease process

dryness of skin can be caused by

Dehydration
Smoking
Stress
Sun exposure
Overuse of Soap
Elderly

excessive dryness of the skin

possibly Eczema or Dermatitis

Temperature assessment of skin indicates

the amount of blood circulating through the dermis. (Warm=More blood Cold=Less blood)

how is skin temperature assessed

palpation
compare symmetry
alert of warmth and erythema (may be pressure injury)

Braden Scale for Predicting Pressure Sore Risk

sensory perception, moisture, activity, mobility, nutrition, friction and shear

T/F Higher Braden Scale score means higher risk for skin breakdown & pressure injuries

False
score of 6 is the highest risk

Highest and lowest Braden score

ranges from
High Risk 6 >>>>> 23 Low Risk

Texture assessment of skin (5)

- Smooth or Rough
- Thin or Thick
- Tight or Wrinkled
- Indurated (hardened)
- Scarred

skin turgor assesses

skin elasticity
hydration
-can be effected by age/edema

skin vascularity assessment

Observe/inspect for
-reddened, pink or pale areas
- Petechiae

Petechiae

Pin-point red or purple spots, Small hemorrhages
- May indicate blood clotting disorders, drug
reactions, or liver disease
looks like a rash but not raised

skin Edema assessment

Observe and palpate for fluid build up in the tissues. If indentation remains after 5 second
push→ pitting edema

Skin edema causes (2)

Direct Trauma
Impaired venous return (heart failure)
More common in dependent areas (feet)

Pitting edema measurement

+1=edema is 2 mm deep
+2=edema is 4 mm deep
+3=edema is 6 mm deep

Skin Lesion assessment

Observe/inspect and palpate
ABCDE skin cancer

Nevus (Nevi, plural)

Mole/Moles

Macules

Flat Lesions

Papules

small raised lesions 1 cm

wheals (hives)

Allergic reaction, elevated lesions cause by localized edema.

Vesicles

filled with clear fluid

Pustules

raised lesions with pus

Ulcers

erosion of the skin

Melanoma

Deadliest form of skin cancer
Begins as a small, mole-like growth

ABCDE of assessing moles

A-asymmetry
B-border irregularity
C-color variations from blue to black
D-diameter greater than 6 mm
E- Evolving

Hair assessment

Color
Distribution
Quantity
Thickness
Texture
Sheen
Hirsutism

hair texture descriptors 3

Thick Thin Brittle

hirsutism

excessive hair growth (occasionally happens in women)

scalp assessment

observe/inspect: lesions, bruises, hair loss, dandruff, psoriasis, lice, ticks, ringworm
palpate: lumps, tenderness

Nail Assessment

-observe/inspect and palpate cleanliness, color (fungus), thickness, texture, shape (clubbing)

Nail shape clubbing is due to

cardiac/pulmonary disorders, chronic hypoxia

Capillary Refill Assessment

-Press patient's nailbed and release
-Normal capillary refill = < 3 seconds
-Abnormal capillary refill = >3 seconds

What causes poor capillary refill

peripheral vascular disease, arterial blockage, heart failure, shock

5 common skin hair and nail nursing diagnosis

Risk for impaired skin integrity
Impaired tissue integrity
Self-mutilation
Impaired elimination
Disturbed body image