HA- Skin, Hair, Nails

what does acrocyanosis look like and what is the cause? who is it found in?

- hands and feet appear blue -happens right after birth, profusion is sluggish -infants and newborns

what are examples of primary lesions?

Macules, patches, papules, nodules tumors, vesicles, pustules, bullae, and wheals, cyst

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?

a neuropathic ulcer can develop without feeling it

what is pallor caused by ?

caused by arterial insufficiency anemia and shock

loss of hair pigmentation starts at the

chin and goes to the back of the head

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

chronic hypoxia

in regards to the shamroth test, what are you testing for?

clubbing of nails

what is a lesion that is walled off containing fluid or semisolid material

cyst

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions?

hypoxia

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 to the client that there is a genetic component with skin cancer, especially

malignant melanoma

what substance contributes to variations in skin color?

melanin

what would we call a lesion that has a irregular shape, >1cm, circumscribed area of different color (vitiligo)

patch

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

what are some examples of vascular lesions

-petechiae -ecchymosis -hematoma

Describe the ABCDE rule when looking at a new skin growth and the danger signs of each

A- asymmetry : shape is not symmetrical B- border irregularity: irregular border C- color (variations) : black, tan, brown, red D- Diameter: > 6mm is concerning E- erosion : how long has it been there, any recent changes in size, color, border or elevation?

What is the most important focus area for the integumentary system?

UV radiation exposure

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

aerial of the breast

what tool is used to predict pressure sore risk?

braden scale

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

distribution

describe a stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both, skin blisters and forms open sores, skin may be sore or reddened

what do we call a lesion that is plateau like, >1cm, flat topped (psoriasis, keratosis)

plaque

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

psoriasis, fungal infections, trauma

when palpating the skin, a normal observation for skin moisture is

should not be wet with perspiration

what are some common lesions?

stretch marks, birth marks, freckles, scars

Connecting the skin to underlying structures is/are the

subcutaneous tissue

describe a squamous cell lesion

- red scaly pattern with uneven margins, redness on hands and head, less common and grows rapidly

what is jaundice caused by?

build up of bilirubin, liver disorder

Describe a stage 1 pressure ulcer

intact skin with nonblanchable redness, discoloration, warmth, edema

what do we call a lesion that is elevated, palpable, filled with purulent fluid (acne, infected hair follicles)

pustule

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

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?

"It takes about 6 months to totally replace a fingernail."

what are the 5 components of the Braden scale?

- sensory perception -moisture -mobility/activity -nutrition -friction and shear

describe a secondary lesions and name some examples

-arise from changes from primary lesions -break in continuity of the skin -fissures -erosions -ulcers -scars

what does milia look like and what is the cause?

-baby acne (usually on face) -caused by hormone changes

describe a malignant melanoma lesion

-brown, lethal, irregular, scaly, notched borders, sun damage

if lesions are observed, what do you observe specifically?

-characteristics such as color, temperature, moisture, skin turgor and skin breakdown

how and where do you assess skin turgor? rationale for that location?

-collar bone, you check for turgor and dehydration here because the skin is thin and pliable. it is the best spot for an accurate response

what does laguno look like and when does it disappear

-extra downy hair on baby shoulder, back and head -disappears by 2 weeks

when assessing skin what are you inspecting for?

-general color and condition -cleanliness and condition of scalp -for amount of hair and distribution

what is erthyma caused by physiologically?

-inflammation -trauma -capillaries dilated

when palpating the nails for texture and consistency what are you identifying?

-jagged or smooth -hard and immobile -any grooves? grooves can indicate acute illness, fever, or dehydration

what is a normal and abnormal color for nails?

-light to pink is normal -extremely pale or cyanotic is abnormal as well as a yellow color shows fungal problems -darker skin tone will show hyperpigmentation of nails and nail beds as abnormal

describe a basal cell lesion

-most common cancerous lesion -round, pearly, middle is red and grows like a spider, common by eyes and nose, very deep

when assessing nails what are you inspecting for?

-nail grooming and overall cleanliness -nail bed color and marking on nails -shape of nails -palpate for texture and consistency and assess capillary refill

what should you include in documentation of a lesion?

-size -location -shape -color -drainage -odor -color of surrounding skin

describe the relationship of skin turgor and dehydration

-skin turgor will allow the skin to be pinched and will not fall back down fast , if this happens you are more than likely dehydrated

what do birth marks look like on infants and what is the cause?

-stork bite, cafe au lait, Mongolian spots -normal, overgrowth of vascular or an area with extra pigment

what does vernix cases look like and what is the cause? who is it found in?

-thick cheesy white stuff, it protects the baby -normal, will absorb into the skin so do not wipe -infants and newborns

decreased vascularity in older adults causes what?

-worsened circulation in extremities, resulting in dehydration, brittle skin, and inflammation

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

if skin breakdown is observed, what assessment tool is used?

PUSH scale

when palpating the skin, a normal observation for skin mobility and turgor is

able to change shape and return to normal

increased sebum production causes what

acne, oil

what do we call a lesion that is an elevated cavity containing fluid, >1cm (blister, burns)

bulla

what do we call a lesion that is an encapsulated fluid filled cavity in dermis or subcutaneous layer, tensely elevating the skin

cyst

what does wrinkles, thin, dry, and less stretchy skin?

decreased collagen and elasticity

what is peripheral cyanosis caused by?

decreased perfusion, deoxygenated hemoglobin, vasoconstriction

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

dermis

The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

dermis

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?

document findings in the clients record as normal

what are some localized color variations to inspect?

freckles, moles, birth marks, suntan areas, patterns

describe a stage 4 pressure ulcer

full thickness skin and tissue loss -damage to muscle, bones, tendons, joints, no pain, undermining and sinus tracts

describe a stage 3 pressure ulcer

full thickness tissue loss with visible subcutaneous tissue, damage to tissue below skin, looks like a crater, adipose tissue visible

what are clustered, fluid filled vesicles?

herpes simplex

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 received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism

what is a bullae that ruptures and oozes shroud fluid forming a honey- colored crust

impetigo

increased apocrine gland secretions result in what

increased sweat production

what is clubbing of nails caused by?

low oxygenation

what do we call a lesion that is flat, circumscribed, less than 1 cm (freckle, nevi, measles)

macule

what do we call a lesion that is elevated, firm, palpable and >1cm (lipoma, fibroma)

nodule

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

osteomyelitis

who is at risk for skin cancer?

pale and fair skin, redheads

what do we call a lesion that is palpable, elevated, firm and <1cm (wart, small nevus)

papule

if the toe nails are very thick what could that indicate?

peripheral vascular disease

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

psoriasis

how do you perform the shamroth test?

put nails together and you should see a diamond shape and cuticles shouldn't touch but if they do they indicates clubbing

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do? and what is this indicative of?

reassure the mother that this is normal - this is an example of peripheral cyanosis, common and benign condition that happens when child is cold and adjusting their peripheral circulation to keep the core warm

what are some common skin breakdown and pressure ulcer areas?

sacrum, coccyx, heels, scapula, head and bony prominences

when palpating the skin, a normal observation for skin edema is

should be able to be compressed and return back to normal, leaving no indentation or divet

when palpating the skin, a normal observation for skin temperature is

should be warm with no areas of temperature increase or decrease

what is the largest organ of the body

skin

when palpating the skin, a normal observation for skin texture is

smooth and dry

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as

stage 2

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

stage 3

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

the client has chronic hypoxia

what do we call a lesion that is elevated, solid, palpable, and >2cm (neoplasms, hemangioma)

tumor

when palpating the skin, a normal observation for skin thickness is

uniform and evenly distributed, no bulges or thick areas

what do we call a elevated cavity containing fluid, <1cm (blister)

vesicle

what do we call a lesion that is superficial, raised, erythematous, edematous (insect bite, allergic reaction)

wheal

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

wood's light