HPA SKIN , HAIR AND NAILS

Pressure ulcer sage II

Broken skin with presence of a blister/superficial skin loss of epidermis alone or w/dermis

Blue color to skin or mucous membranes due to increased amount of unoxygenated hemoglobin (decreased perfusion). Dark-skinned look for changes in level of consciousness and signs of respiratory distress.

Cyanosis

Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin

Cyst

encapsulated fluid-filled or semisolid mass of subcutaeous tissue

Cyst

Diameter greater than 6mm

D

Look in oral mucous membranes. Normally looks smooth and dry. Dark skin may look dry and flaky but thats normal. Abnormal looks dry and lips look parched and cracked.

Dehydration

-AKA fingerprints -Connects the dermis to the epidermis

Dermal Papillae

-Inner layer of skin -Made up of connective tissue that contains collagen and elastic fibers -Origin of sebaceous glands, sweat glands, hair follicles

Dermis

Vascular; when you cut yourself its the dermis that bleeds and hurts; connective tissue/collagen and elastic tissue

Dermis

Profuse perspiration, accompanies an increased metabolic rate, such as in heavy activity or fever

Diaphoresis

Distinct, individual lesions that remain separate

Discrete

For superficial ulcers, new pink or shiny tissue that grows in from the edges or as islands on the ulcer surface

Epithelial Tissue

What does the Erector Pilli muscle do?

Erector Pilli muscle responds to cold or fright, causing hair to stand erect

Intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries, as in fever or inflammation. Dark skinned can't see redness so palpate the skin for increased warmth, taut or tightly pulled surfaces, hardening of deep tissues or blood vessels.

Erythema

Self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching

Excoriation

Linear crack with abrupt edges, extends into dermis, dry or moist

Fissure

An adult male client visits the clinic and tells the nurse that he believes he has athelete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the present of

Fissures

Pink or beefy red tissue with a shiny, moist, granular appearance

Granulation Tissue

Clusters of lesions

Grouped

Twisted, coiled spiral, snakelike

Gyrated

Color, texture, distribution, lesions

Hair

What type of cell tissue is hair made up of?

Hair consists of layers of keratinized cells found over most of body except sensitive/private areas

Where does a hair develop?

Hair develops within epidermis at base of hair follicle where it is nourished

Skin lesion due to benign proliferation of blood vessels in the dermis

Hemangioma

A bruise you can feel. It elevates the skin and is seen as swelling

Hematoma

Traumatic or pathological changes in previously normal structures

Lesions

Tightly packed set of papules that thickens skin. From prolonged intense scratching. Looks like surface of moss (or lichen)

Lichenification

Scratch, streak, line, or stripe

Linear

Benign fatty tumor

Lipoma

Softening of skin tissue by soaking

Maceration

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain t the client that there is a genetic component with skin cancer especially

Malignant Melonoma

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

Malucles

Skins ease of rising; reflects the elasticity of the skin

Mobility

Red-pink tones of oxygenated hemoglobin in blood is lost, skin takes on the color of CT/collagen. Looks pale/white. Dark-skinned absence of underlying red tones that normally give it luster. Looks yellowish-brown, ashen, or gray.

Pallor

Something you can feel (solid, elevated, circumscribed, <1cm); caused by superficial thickening in epidermis (moles)

Papule

Macules that are larger than 1cm

Patch

Papules coalesce (come together) to form surface elevations wider than 1cm. A plateaulike, disk-shaped lesion.

Plaque

While assessing an adult client, the nurse observes an elavted, palpable, solid mass with a circumscribed border that measures 1 cm. The nurse documents this a

Plaque

Annular lesions grow together

Polycyclic

When a lesion develops on previously unaltered skin

Primary Lesions

View the index finger at its profile and note the angle of the nail base; Normal 160 degrees or less.

Profile sign

Itching

Pruritus

Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells

Scale

After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change

Scar

A dark- skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's

Sclera

-All over body because they attach to hair follicles -Secrete an oily substance known as sebum

Sebaceous Gland

Produce a protective substance that is secreted through hair follicles, which oils and lubricates the skin and hair and retards water loss from skin

Sebaceous glands

When a lesion changes over time or changes because of a factor such as scratching or infection

Secondary Lesions

Protective barrier, prevents penetration, perception (self-concept), temp regulation, identification (ethnic groups), communication, wound repair, absorption and excretion, production of vitamin D

Skins functions

Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps

Slough

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

Squamous cell carcinomas are most common on body sites with heavy sun exposure

Horny cell layer; cells constantly shed

Stratum Corneum

Basal cell layer; inner layer; forms new skin cells; produce melanin

Stratum Germinativum

The darker thicker hair that grows on the scalp, eyebrows, pubic area, axillae, face, and chest

Terminal hair

-AKA peach fuzz -Short, pale, fine, and present over most of body

Vellus Hair

Hair fine, faint hair that covers most of the body

Vellus hair

Elevated cavity containing free fluid, up to 1cm; a blister. Clear serum flows if wall is ruptured (herpes)

Vesicle

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the size of the client's

Vesicles

a macular or papular rash

Viral exanthem

The skin plays a vital role in temperature maintenence, fluid and electrolyte balance, and synthesis of vitamin

Vitamin D

A client's skin color depends on melanin and carotene contained in the skin and the

Volume of blood circulating in the dermis

Raised red skin lesion due to interstitial fluid(erythematous); transient(lasting a short time); slightly irregular shape due to edema (mosquito bite)

Wheal

Pallor is considered

abnormal

Skin odor is considered

abnormal

Skin redness accompanied by warmth is considered

abnormal

Skin fluoresces blue-green under UV light is considered

abnormal (indicates fungus)

>2 second capillary nail-bed refill

abnormal due to respiratory or cardiovascular disease causing hypoxia

Beau's lines are indicative of

acute illness (will eventually grow out to normal)

Increased angle of the between nail base and skin greater than 180 degrees

clubbing → occurs with hypoxia and therefore cigarette smokers.

Excessive scaliness on scalp may indicate

dermatitis

Chemical exposure to nails

dry, splinter hemorrhage due to trauma of nail bed

Decreased skin mobility is associated with

edema

Skin losing its turgor because of a decrease in elasticity and collagen fibers is associated with

elderly people

Iron deficiency anemia is associated with

hair loss

generalized hair loss for several months may indicate

hypothyroidism

Dull, dry hair can be associated with

hypothyroidism; malnutrition

Pressure ulcer sage IV

muscle, bone, & other supportive tissue affected

A solid palpable mass

nodule

When poor hygiene is observed, the nurse should remain

non-judgemental

Amounts of melanin found in darker or olive skinned people is considered

normal

Freckle-like pigment in dark skinned person's nail bed is considered

normal

Frecklelike or dark streaks of pigmentation in sclera and nailbeds in dark skinned people is considered

normal

Freckles are considered

normal

Lighter-colored palms, soles, nailbeds, and lips in dark skinned people is considered

normal

Pinch skin & easily and immediately returns to its original position in younger to middle aged clients is considered

normal

Pinch skin & easily and it DOSN'T immediately returns to its original position in older clients is considered

normal

Sagging or wrinkled skin appeared in the facial, breast, and scrotal areas is considered

normal

Small amounts of melanin in whiter skinned people is considered

normal

Sparse dandruff is considered

normal

Stretch marks are considered

normal

Unremarkable moles are considered

normal

Calluses are considered

normal (when skin is under constant pressure)

Dark skinned clients may have

thicker nails (normal)

Older clients may have nails that appear

thicker, yellow, brittle because of decreased circulation of extremities.

Pustules with hair loss in patches can be associated with

tinea capitis (contagious fungal infection)

Full-thickness tissue loss where base of ulcer is covered by slough (yellow, tan, gray, brown) and/or eschar (tan, brown or black) in wound bed

unstageable

White patches are called

vitiligo

use cm

Size

3 layers: epidermis, dermis, subcutaneous layer

Skin

Note any color or odor

Exudate

A primary function of hair in the nose and eyelashes is to serve a

Filter for Dust

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate

Fluid Intake

(boil) suppurative inflammatory skin lesion due to infected hair follicle

Furnucle

localized collection of blood creating an elevated ecchymosis associated with trauma

Hematoma

Cushing's disease is associated with

Hirsutism (facial hair on females) due to imbalance of adrenal hormones.

Occurs with an increased metabolic rate such as in fever or after heavy exercise. trauma, infection, or sunburn

Hyperthermia

Generalized coolness. Used for surgery or high fever. expected with immobilized extremity

Hypothermia

A 20 year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not recieved radiation or chemotherapy, the nurse should further assess the client for signs and symtpoms of

Hypothyroidism

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

Hypoxia

Shape and contour, consistency, color

Nails

Black, brown, or tan tissue that adheres firmly to the wound bed or ulcers edges and may be either firmer or softer than surrounding skin

Necrotic Tissue

Circumscribed skin lesion due to excess melanocytes

Nevus (mole)

Elevated skin lesion, >1 cm diameter

Nodule

Solid, elevated, hard/soft, >1cm. May extend deeper into dermis than papule.Nodule solid, elevated, hard/soft, >1cm. May extend deeper into dermis than papule.

Nodule

Dry, itchy skin is common in

Obese clients

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

Oral mucosa

Squamous cell carcinoma is associated with

Overall amount of sun exposure

Raised lesions on scalp may indicate

infections or tumor growth

Skin redness accompanied by warmth is a sign of

inflammation, allergic reactions, or trauma

Lesions often result from

irritation or disease

Nail disorders may be indicative of

local problem and/or systemic problem

Is it generalized, localized to area of a specific irritant; around jewelry, watchband, around eyes

location and distribution on body

Flat non-palpable skin color change that can be brown, red, white, tan, or purple is called

macule

Whiteheads/tiny white facial papules on infants face

milla (usually disappear spontaneously within a few weeks of birth)

Healed scars are considered

normal

Somewhat paler appearance is considered normal in

older people (due to decreased melanin production and decreased dermal vascularity)

Clubbing of the nails is indicative of

oxygen deficiency

Mottlling of the skin is associated occurs when

oxygenation is altered to skin or tissue

Skin breakdown as reddened areas can result in

painful pressure ulcers

Assess skin texture by palpating with

palmar surface of three middle fingers

An elevated palpable, solid mass that is smaller than a nodule

papule

Infection of the nailbed is called

paronychia

Lupus erythematosus is associated with

patchy skin & butterfly rash on face

The grouping or distinctness of each lesion; annular, grouped, confluent, linear

pattern or shape

Very dry scalps and dry, fragile hair is normal in

people of African decent

Blue-tinged fingers and toes due to vasoconstriction

peripheral cyanosis

Round red or purple macule 1-2mm

petechia

To assess skin turgor

pinch skin on sternum to determine how quickly it returns to shape

Potential cause of skin odor

sweat gland disorder or poor hygiene

A circumscribed, elevated mass with fluid

vesicle or bulla (determined by size)

Fungal nail infection

yellow discoloration

Linear arrangement along a nerve route

zosteriform

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

Stage II

-Last layer of skin, below the dermis -Contains fat cells, blood vessels, nerves, etc. -Insulates internal body heat -Protects/cushions bones and internal organs

Subcutaneous

Layer made up of adipose tissue (fat), aids protection by cushioning,

Subcutaneous

Connecting the skin to underlying structures is/are the

Subcutaneous tissue

previous history of skin disease, change in mole, change in pigmentation (size or color), excessive dryness or moisture, pruritus (itching), excessive bruising, rash or lesion, medications, hair loss, change in nails, environmental or occupational hazards, self-care behaviors

Subjective data

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. the nurse should further assess the client for

Symptoms of stress

Iris, resembles iris of eye, concentric rings of color in the lesions

Target

Skin lesion due to permanently enlarged and dilated blood vessels that are visible

Telangiectasia

-Characterized as the scalp or eyebrows -Usually darker, longer, coarser hair -Puberty initiates the rest of terminal hair mostly in armpit, legs, and private areas

Terminal Hair

An oily scalp is considered

abnormal

Cold skin is considered

abnormal

A sudden abnormal patchy loss of hair

alopecia --> may result from infections, discoid or SLE, and some chemo.

Blue-tinged color around abdomen & chest

central cyanosis

Blue-tinged color around lips and mouth

circumoral cyanosis

Pustules on scalp is a sign of

folliculitis (infections of the hair follicle)

Asians and Native Americans

have fewer sweat glams & body odor

Cold skin can be a sign of

hypotension; arterial disease

Rough, flaky, dry skin is seen with

hypothyroidism

Honey colored exudate in a vesicular rash is indicative of

impetigo

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

Areola of the breast

Pallor (loss of color) is considered abnormal. What are possible causes?

Arterial insufficiency Decreased blood supply Anemia

Very thin skin can be associated with

Arterial insufficiency or in those on steroid therapy

To assess for anemia in a dark- skinned client, the nurse should observe the client's skin for a color that appears

Ashen

Resulting skin level depressed with loss of tissue; a thinning of the epidermis

Atrophic Scar

Border irregularity: notching, scalloping, ragged edges or poorly defined

B

An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "results of an accident." The nurse suspects that the client may be experiencing

Domestic Abuse

Elevation and enlargement

E

Round irregular macular lesion

Ecchymosis

Hair follicles, sebaceous glands, and sweat glands originate from the

Eccrine Glands

Produces dilute saline solution (sweat)

Eccrine glands

Fluid accumulating in the intercellular spaces

Edema

Allows the skin to stretch with body movements

Elastic tissue

Flat or raised

Elevation

Appendages hair, sebaceous glands, sweat glands (eccrine and apocrine), nails

Epidermal

-Outer layer of skin composed of 4 layers -Completely replaced every 3-4 weeks -Stratum germinativum undergoes cell division and contains melanin

Epidermis

Avascular; just a protective layer; uniformly thin; derivation of skin color; 2 layers-stratum germinativum and stratum corneum

Epidermis

Press down and color disappears then release and color reappears quickly

Blanching

While assessing an adults client's feet for fungal disease using a wood light, the nurse documents the presence of a fungus when the fluroescence is

Blue

Elevated cavity containing free fluid larger than 1cm diameter; usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily (burns)

Bulla

Color variation: areas of brown,tan, black, blue, red, white, or combination

C

Scooped out, shallow depression. superficial; epidermis lost; moist but not bleeding; heals without scar because is does not extend into dermis

Erosion

Depress the nail edge to blanch and then release, noting the return of color in 1-2 seconds

Capillary refill

orange skin pigment from excessive carotene intake (carrots or vegetables with the orange pigment)

Carotenemia

Pressure ulcer sage III

epidermis dermis, & subcutaneous breakdown

dehydration can be revealed on the skin by

examining for decreased turgor

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are

Caused by aging of the skin in older adults

Asymmety: not regularly round or oval, two halves of lesion do not look the same

A

Overly warm skin can be a sign of a

febrile state; hyperthyroidism

The nurse is assessing an African American client's skin. After the assessment, the nurse should instruct the client that african american persons are more susceptible to

Chronic discoid lupus eyrthematosus

The nurse is assessing a dark- skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue- tinged lips and oral mucosa, the nurse should document the presence of

A great degree of cyanosis

The wound is completely covered with epithelium

Closed/Resurfaced

While assessing the nails on an adult client, the nurse observes Beau lines. The nurse should ask the client if has had

A recent illness

Flattening of the angle between the nail and its base to 180 degrees

Clubbing

Diaphoresis (profuse sweating) can be accompanied with

fever; hyperthyroidism

Flat skin lesion with only a color change

Macule

Flat skin lesion with only a color change. < 1cm (freckles)

Macule

Elevated mass with transient boarders

Wheal

mnemonic for melanoma A B C D E

A=asymmetrical B=irregular boarders C=color variations D=diameter 1/8" to 1/4" E=elevated

Danger signs for abnormal characteristics or pigmented lesions

ABCDE

Epidermis's outer layer thins and flattens. Wrinkling occurs bc the underlying dermis thins and flattens. Less elasticity/elastin, collagen, and subcutaneous fat. Reduction in muscle tone. Sweat glands and sebaceous glands decrease in number and function, leaving dry skin.

Aging Adult Skin

baldness (hair loss)

Alopecia

Circular; begins in the center and spreads to periphery (ring worm)

Annular

Produce a thick milky secretion and produces a musky odor

Apocrine glands

What are some Characteristics of Nails?

-Located on distal end of phalanges and toes -Grows from cuticle -Nail body extends over entire nail bed and has a pink tinge to it because of underlying blood vessles -Protects distal end of fingers and toes

What are the two types of sweat glands and what is their purpose?

1. *Eccrine sweat gland*- located all over the skin; secretes sweat and thermoregulates body 2. *Apocrine sweat gland*- associated with hair follicles in sensitive/private parts of the body; non-functional until puberty; linked with menstrual cycle

What are the three layers of the skin?

1. Epidermis 2. Dermis 3. Subcutaneous

What are the 4 layers of the Epidermis?

1. Stratum corneum 2. Stratum lucidum 3. Stratum granulosum 4. Stratum germinativum

What are the 2 types of hair?

1. Vellus 2. Terminal

angle between nail base & skin

160-degrees

Lesions run together (hives)

Confluent

Tough fibrous protein that enables the skin to resist tearing

Connective tissue/collagen

A large patch of capillary bleeding into tissues. Color is red-blue or purple immediately after or within 24hrs >blue to purple>blue-green> yellow >brown-disappearing. Bruise in dark skinned is deep dark purple. Pressure on bruise does not cause it to blanch

Contusion/bruise

Lunula

Crescent shaped area located at base of nail

Thick, dried-out exudate left when vesicles/pustules burst or dry up. Color red-brown, honey, or yellow, depending on the fluids ingredients

Crust

The only layer of the skin that undergoes cell divisions is the

Innermost layer of the epidermis

Target shape of skin lesion

Iris

Spoon nails are indicative of

Iron deficiency

Yellow color to skin, palate, and sclera due to excess bilirubin in blood. Early jaundice in sclera and hard palate.

Jaundice

An African American female client visits the clinic. She tells the nurse that she had her ears peirced several weeks ago, and an elevated, irregular, reddened mass how now developed at the ear lobe. The nurse should document a

Keloid

Hypertrophic scar. Elevated beyond site of original injury by excess scar tissue. May increase long after healing occurs. looks smooth, rubbery, "clawlife", and has a higher incidence among blacks.

Keloid

The nails, located on the distal phalanges of the fingers and toes, are composed of

Keratinized epidermal cells

Nail problems may arise from

Psoriasis Fungal infections Trauma

Red-purple skin lesion due to blood in tissues from breaks in blood vessels

Purpura

Elevated cavity containing turbid fluid (pus); acne

Pustule

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight 3 times a week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

Risk for Ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lessions.

Compact desiccated flakes of skin from shedding of dead skin cells

Scale

Larger than a few cms in diameter, firm or soft, deeper into dermis; may be benign or malignant

Tumor

It's ability to return to place promptly when released; reflects the elasticity of the skin; used to determine dehydration

Turgor

Sloughing of necrotic inflammatory tissue that causes a deep depression in skin. Extending into dermis; irregular shape; may bleed; leaves scar when heals

Ulcer

skin loss extending past epidermis

Ulcer

Skin integrity of obese female clients should be checked

Under the breast, limbs, or groin (due to these areas having high friction and moisture)

To assess an adult's clients skin turgor, the nurse should

Use two fingers to pinch the skin under the clavicle

Short, Pale and fine hair that is present over much of the body is termed

Vellus

linear crack in the skin

fissure

Decreased moisture can be associated with

dehydration; hypothyroidism

Rough dark skin around the neck is an indication of

diabetes mellitus

Term for a patient with profuse sweating

diaphoresis

Assess skin texture by palpating

dorsal/palmar surface of hands and fingers

Silvery white appearance of the skin

psoriasis

Pressure ulcer sage I

red without skin breakdown

Normal, blemishes on skin associated with aging and UV from sun. From light brown to red or black and are located in areas most exposed to sun (hands, face, shoulders,arms and forehead)

senile lentigines (liver spots)

Cold skin can be a sign of

shock

Clammy skin is typical with

shock; hypotension