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Health Assessment
Skin, Hair, Nails
| Question | Answer |
|---|---|
| What are characteristics of skin of young people? | Smooth, firm, good turgor, durable, quick repair, adolescents tend to get oily skin/acne due to increase in sebaceous gland activity |
| What are characteristics of skin of the elderly? | Bruise easily, liver spots, dry/flaky, loose, decreased turgor (skin tents), skin tags occur, prominent changes in skin color/pigmentation, fat diminishes causing skin to be thin and fragile, does not heal quickly |
| What are some health history questions used to collect subjective data for the skin, hair, and nail assessment? | Past history of skin disease? Change in pigmentation? Change in size or color (moles)? Any excessive dryness or moisture? Excessive bruising? Any rash or lesions? Hair loss? Nail color changes? Environmental hazards? On meds? Pt. centered care? |
| Describe various lesions that could be found on the body | Macules, patches, papules, plaques, nodules, tumors, wheals, urtucaria (hives), vesicles, bullas, pustules, cysts |
| What is a macule? | Solely a color change, flat, circumscribed, <1cm Ex: Freckles, flat nevus, petechia, measles, scarlet fever |
| What is a patch? | A macule larger than 1 cm Ex: mongolian spots, vitiligo, cafe-au-lait spot, chloasma, measles rash |
| What is a papule? | Something you can palpate; solid, elevated, circumscribed lesion <1 cm in diameter Ex: Moles, warts |
| What is a plaque? | A papule wider than a cm; plateau like, disc-shaped lesion Ex: psoriasis, lichen planus |
| What is a nodule? | Solid, elevated, hard or soft lesion larger than 1 cm; may extend deeper into the dermis than papule. Ex: xanthoma, fibroma, intradermal nevus |
| What is a tumor? | Lesion larger than a few cm in diameter, soft or firm, deeper into dermis; may be benign or malignant Ex: Lipoma, hemangioma |
| What is a wheal? | A superficial, raised, transient, and erythematous lesion; has slightly irregular shape caused by edema Ex: Mosquito bite, allergic reaction, dermographism |
| What are hives? | Wheals coalesce to form extensive reaction to something |
| What is a vesicle? | An elevated cavity containing free, clear fluid up to 1 cm Ex: Herpes simplex, early varicella (chicken pox), herpes zoster (shingles), contact dermatitis |
| What is a bulla? | Larger than 1 cm in diameter; usually single chambered; superficial in epidermis; thin walled so it ruptures easily Ex: friction blisters, burns, contact dermatitis, pemphigus |
| What is a pustule? | Turbid fluid (pus) in cavity, circumscribed and elevated Ex: Impetigo, acne |
| What is a cyst? | Encapsulated, fluid filled cavity in dermas or subcutaneous layer that tensely elevates the skin Ex: Sebaceous cyst, wen |
| What are characteristics of Stage 1 pressure ulcers? | Intact skin appears red but unbroken; localized redness in light skin blanches (turns light with fingertip pressure) Dark skin appears darker but does not blanche |
| What are characteristics of Stage 2 pressure ulcers? | Partial thickness skin erosion with loss of epidermis or also the dermis; superficial ulcer looks shallow, like an abrasion or open blister with a red-pink wound bed |
| What are characteristics of Stage 3 pressure ulcers? | Full thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater; may see subcutaneous fat, but NOT muscle, bone or tendon |
| What are characteristics of Stage 4 pressure ulcers? | Full thickness pressure ulcer, involves all skin layers and extends into supporting tissue; exposes muscle, tendon, or bone and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue) |
| What are the guidelines for teaching patients self-care evaluation? | 1.Undress completely: Check forearms, palms, space btwn. fingers, back of hands, 2. Face mirror, bend arms @ elbow, study arms in mirror, 3. Face mirror and study entire body front starting @ face/neck and working way down torso/legs |
| Guidelines for teaching patients self-care evaluation cont'd | 4. Pivot to have right side facing mirror, study sides& upper arms, working down to ankles, Repeat with left side, 5. With back to mirror, study buttocks, thighs& lower legs, 6. Use handheld mirror to study upper back, scalp, 7. inside legs, soles of feet |
Created by:
amandamarie194
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