Skin/Hair/Nails

Large Fluid-filled Blister (>1cm)

Bulla

Bulbous enlargement of fingertips and nails, seen from chronic low oxygen

clubbing

Lesions that run together and merge

confluent

Bluish discoloration of skin or mucous membranes from low oxygen

cyanosis

A Bruise; Bleeding under the skin (>1cm)

ecchymosis

Redness of skin from inc blood flow

Erythema

Yellowing of skin or eyes from bilirubin buildup

jaundice

Thick, raised scar that grows beyond the original wound edges

keloid

white spots or streaks on the nails

Leukonychia

lesions arranged in a line

linear

flat, distinct, colored area (<1cm) freckle

macule

moles; benign pigmented growths

nevi

Solid, raised, solid lesion (<1cm) extends deeper than papule

nodule

Paleness of skin from low blood flow or anemia

pallor

Small, raised, solid lesion (<1cm) mole or wart

papule

Flat, discolored area (>1cm) birthmark

patch

Tiny pinpoint red/purple spots from small blood vessel bleeding

petechiae

Raised, flat-topped lesion (>1cm) psoriasis

plaque

Small, raised, pus filled lesion (acne)

pustule

General term for widespread skin eruption

rash

Fibrous tissue, replacing normal skin after injury

scar

Stretch marks, linear marks from skin stretching

striae

Elasticity of the skin; reflects hydration status

turgor

Small fluid-filled blister (<1cm) chickenpox

vesicle

Lesions arranged in band-like pattern along a nerve (shingles)

zosteriform

5 functions of the skin

protection, temp regulation, sensation, vitamin D prod, and excretion

what are the 2 main skin, hair, and nails assessments?

inspection and palpation

what 4 things do you look for when inspecting skin, hair, and nails?

color, lesions, vascularity, and hygiene 

what 5 things do you feel for when palpating skin, hair, and nails?

temp, moisture, turgor, texture, thickness

what 4 things do you note when inspecting and palpating hair?

color, texture, distribution, scalp lesions 

what 6 things do you inspect for when you assess nails?

shape, contour, thickness, color, cleanliness, and cap refill

capillary refill in nails should be < ____sec.

2

what are 4 abnormal color findings in a hair, skin, and nail assessment?

cyanosis, jaundice, pallor, erythema

what are 7 abnormal lesion findings in a hair, skin, and nail assessment?

macules, papules, nodules, plaques, pustules, vesiciles, bullae

what are 3 abnormal nail disorder findings in a hair, skin, and nail assessment?

clubbing, spoon nails, and leukonychia

infant and children skin

• __________, more __________

• less _______________ _______ (risk of _____loss and ____________)

thinner, permeable, subcutaneous fat, fluid, hypothermia

Adolescent Skin

• ______________ changes increase ____________ ________ activity

• hair growth increases in _______, _______ region, and ______.

hormonal, sebaceous gland, axillae, pubic, face

Pregnant Woman Skin

• inc ___________

• increased ________ ________ leads to ________ and _______ ________.

pigmentation, blood flow, warmth, spider angiomas

what are the 3 kinds of inc pigmentation seen in pregnant women?

linea nigra, chloasma, and striae

Older Adult Skin

• ___________, less ________, dec ________ leading to wrinkles and dryness

thinner, elastic, turgor

Older adult skin is more _______, with slower wound __________, and easy ___________.

fragile, healing, bruising

Older Adults have ______, grey hair, and _____, _______ nails.

thin, thick, brittle

what 3 skin conditions are common in older adults?

liver spots, seborrheic keratoses, and cherry angiomas

what 4 skin conditions are common in infants/children?

milia, mongolian spots, cafe au lait spots, and diaper rash

If patient skin is dark rely more on…(3) for assessing color changes

palms, soles, mucous membranes

with older adults expect ________, wrinkes, ____ spots, and _______ skin.

dryness, age, fragile

check _____ __________ for pressure injuries in Bedridden patients

bony prominences

when assessing skin always distinguish between _________ _________ and abnormal findings.

normal variation

The ability of skin and mucous membranes to maintain normal physiological processes

tissue integrity

what are 5 risk factors contributing to poor tissue integrity?

age, poor nutrition/hydration, immobility and pressure, chronic illness, and trauma/surgery

what are 5 consequences of impaired integrity?

pain, infection, fluid/electrolyte imbalance, poor thermoregulation, altered body image

when assessing skin integrity check for…(5)

redness, lesions, wounds, moisture, tugor, temp

what are 6 interventions that improve tissue integrity?

repositioning, hygiene, moisturizing, adequate protein/hydration, wound care, and pressure relieving devices

maintenance of tissue integrity requires adequate…(3)

perfusion, oxygenation, and nutrition

__________ _________ or ________ ________ can create sustained pressure over bony prominences.

limited mobility, tactile perception

altered __________ can contribute to skin impairment.

elimination

impaired tissue integrity can cause…

pain

What are 4 parts of Present Health Status (for hair skin and nails)?

allergies, meds, chronic illnesses, changes in skin, hair, nails

What are 4 parts of Past Health History (for hair skin and nails)?

skin disease, infections, trauma, skin cancer

What are 2 components of Family History (for hair skin and nails)?

skin diseases and autoimmune diseases

4 parts of Personal and Psychosocial History (for hair skin and nails)?

skin hygiene, sunscreen use, UV exposure, and occupational exposure

a ____________ _________ _______________ is always done upon admission to a hospital or nursing facility.

comprehensive health assessment

what 6 things do you assess for with skin palpation?

texture, temp, moisture, mobility, turgor, and thickness

what 3 things do you assess for with skin inspection?

color, pigmentation variation, and lesions

understanding and assessing clients skin color (not same as race or ethnicity) and possible variations of findings

color awareness

neglecting to consider the client’s skin color, can lead to incorrect assessment

color blindness

incorrect assessments can lead to missed or __________ __________ and/or__________

inappropriate, diagnosis, treatments

________ __________ can help improve clinical care in clients of all colors.

color awareness

for Baseline Skin color refer to ________ _________ ________.

upper, inner, arm

general color of skin should be…

even

________, _________ ________, and __________ are more vascular and appear more reddish, purple or even pale.

cheeks, upper chest, genitalia

in dark skinned patients palms and soles of feet will typically be _______ than the rest of the skin.

lighter

areas of sun exposure may show…

darker pigmentation

expect skin color ranges from ______ _____ to _______ to _______ _______.

whitish pink, olive, deep brown

white patches on skin occurring anywhere due to autoimmune disorder melanocytes are destroyed

Hypopigmentation Vitiligo

Vitiligo or Hypopigmentation are due to an…

immune disorder

usually only on the face, common in women, associated with hormonal changes and worsened with exposure to sun

hyperpigmentation, melasma

hyperpigmentation: melasma is also known as…

chloasma

what is the “mask of pregnancy” that fades away a few months after delivery?

hyperpigmentation, melasma

what causes Hyperpigmentation: Hemosederin Staining?

chronic venous insufficiency

what are 5 risk factors that could lead to hyperpigmentation: hemosederin staining?

advanced age, obesity, previous blood clots, injuries, and surgeries to legs

poor venous return from legs with fluid back up and red blood cells from capillaries into interstitial tissues causes…

Hyperpigmentation Hemosederin Staining

non-harmful markings seem in obesity, pregnancy, or areas of rapid growth

straie

straie are most commonly seen with…(3)

pregnancy, obesity, areas of rapid growth

straie generally ______ or appear more ________ colored overtime.

fade, silvery

what appears ashen gray on darker skin?

cyanosis

what is harder to see on darker skinned patients that has deeper bluish or black tone?

ecchymosis

what is hard to see and has a deeper brown or purple tone on dark skinned patients?

erythema

what appears lighter, more yellowish, brown, or ashen and is seen in conjunctiva of darker skinned patients?

pallor

what is hard to see, but may be seen in oral mucosa or sclera of darker skinned patients?

petechiae

bruising on lighter skin appears…

dark red, purple, yellow, or green color (depending on age of bruise)

a patient with light skin comes in with reddish tone due to cellulitis, inc skin temp, and tenderness with palpation to inflammation. what condition is this?

erythema

dark skinned patient comes in with deeper brown or purple skin tone due to cellulitis, inc skin temp, and tenderness with palpation secondary to inflammatory. what is this condition?

erythema

what are 2 causes of jaundice?

medications, liver or gallbladder disease

light skinned patient comes in with small reddish/purple pinpoint lesions what condition is this?

petechiae

petechiae is a caused by…

broken capillaries

petechiae is _____, not _______ and not a ______.

flat, itchy, rash

petechiae can be _______ or ________.

benign, serious

Petechiae in darker skinned patients can be more evident in ______ mucosa of mouth or ______ of eye.

buccal, sclera

on dark skinned patients rashes may be _________ but not visible.

palpable