health assessment Ch 14 Assessing Skin,Hair & Nails (prep u)

Vesicles

Around the mouth and chin

Herpes simplex

Clustered fluid-filled vesicles, along a dermatone.

Cyst

Lesions that is walled of containing fluid or semisolid material.

Impetigo

Bullae that rupture and ooze serous fluid forming a honey colored crust. Lesion with necrotic tissue loss.

Stage I Pressure injury

Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Stage II Pressure Injury

Partial thickness of loss of dermis presenting a shallow open ulcer with a red pink wound bed without slough. (Maybe present with open/ruptured serum filled blister).

Stage III pressure Injury

Fully thickness tissue loss. (Subcutaneous fat may be visible but bone, tendon or muscle isn’t exposed).

Stage IV Pressure Injury

Full-thickness tissue loss with exposed bone, tendon, or muscle. ( slough or eschor may be present on some parts of the wound bed). Osteomyelitis possible.

Peripheral Cyanosis

Usually a local problem manifestations of cyanosis. A blue tinged color to the skin. Caused by problems resulting in vasoconstriction. (Found in fingers and toes arm and legs).

Circumoral

Changes in color around the mouth.

Central Cyanosis

Bluish tints to the chest and abdomen cyanosis.

Wood’s light

Used to check for presence of fungus.

Peripheral cyanosis

(Common in kids) benign condition that occurs when child is slightly cold. Adjust peripheral circulation to keep the core warm.

Friction/ Shear forces

Risks that breaks in skin integrity that occurs when pulling a client up in bed alone.

Tinea Corporis

Lesion that is circular. (Annular configuration)

Multiple Nevi.

Lesions that are individual and distant (Discrete configuration).

Tinea versicolor

Smaller legions that run together to form larger legions. (Confluent configuration).

Herpes Simplex

Lesions that are grouped together. (Clustered configuration).

Nail problems

Psoriasis, fungal infections & trauma.

Skin conditions

Vitiligo, vitamin deficiency, eczema, melanoma, & herpes zoster.

Hair conditions

Hirsutism & alopecia.

Plaque Psoriasis

Extreme rash over knees & elbows.

malignant melanoma

A genetic component is associated with skin cancer, especially