Chapter 11- Skin, Hair, Nails Assessment

psoriasis or lichen simplex

plaque lesions may indicate what?

patients with decreased sensory perception (e.g. diabetes neuropathy, venous insufficiency, other sensory deficits) because they cannot sense discomfort associated with decreased circulation to an area caused by prolonged pressure

pressure ulcers are amplified in what types of patients?

acne, furuncles, and carbuncles

pustular lesions may indicate what?

indicates chronic hypoxia. it is identified when the angle of the nail to finger is more than 160 degrees

what does clubbing indicate?

redness

what does erythema mean?

the patient's hydration, nutrition, emotional status, and helps you point in the direction of other systems or organs that may be compromised.

what does integumentary findings reflect in patients?

it gradually loses elastin, collagen, and subcutaneous fat, resulting in overall thinner skin

what happens to an individual's skin is they get older?

self skin-examination

what helps patients identify potentially problematic lesions through the detection of moles

southeast asian men

what heritage has less body and facial hair

immobility of the body or a body part

what increases risks for pressure ulcers?

superficial ulcer without subcutaneous tissue involvement

what is a grade 1 ulcer?

ulcer that penetrates through the subcutaneous tissue (may expose bone, tendon, ligaments, or joint capsule)

what is a grade 2 ulcer?

ulcer with osteitis, abscess, or osteomyelitis

what is a grade 3 ulcer?

hair on the beard area, abdomen, upper back, shoulder, sternum, and inner upper thigh

what is an indication of ovarian dysfunction

pediculosis

what is another name for lice?

bluish discoloration

what is cyanosis?

more than 50 normal moles which can increase risk for melanoma

what is dysplastic nevi

the yellow tone in a baby's skin

what is jaundice?

lesions over the entire body, including palms and soles

what is linked to syphilis?

dependent redness

what is rubor?

Asymmetry Border irregularity Color Diameter of more than 6 mm Evolution of Lesions over time

what is the ABCDE method of melanoma detection?

Reduce the rate of melanoma cancer deaths. Increase the proportion of persons who use at least one of the following protective measures that may reduce the risk of skin cancer: avoid the sun between 10 AM and 4 PM, wear sun-protective clothing when exposed to sunlight, use sunscreen with a sun protection factor (SPF) of 15 or higher, and avoid artificial sources of UV light.

what is the Health People 2020's goals for integumentary health

serous (clear) sanguinous (bloody) serosanguineous (mixed) fibrinous (sticky yellow) purulent (pus)

what is the classification of wound drainage?

a measure of skin elasticity, decreases as a result of thinning of the dermis and reduced elastin production

what is turgor?

an area of no pigmentation

what is vitiligo?

pityriasis rosea which is commonly present with papular, maroon, or purple lesions in African Americans

what presents as a macular hyperpigmented viral dermis in Caucasians?

is the border ragged or notched?

what question do you ask to assess border irregularity

is the diameter greater than 6 mm (pencil eraser)

what question do you ask to assess diameter?

has the lesion evolved or changed over time?

what question do you ask to assess evolution?

does one half look like the other half?

what question to do you ask to assess asymmetry

does the mole have a variety of shades or different colors?

what questions do you ask to assess color?

dehydration, cyanosis, or impaired skin integrity

what skin findings require prompt evaluation and intervention with fluids, oxygen administration, skin repair, or a combination?

in the extremities, particularly the hands and feet

where is decreased vascular supply located?

it follows a dermatome and is often found on the chest, back, abdomen, and face. rarely on the extremeties

where is herpes zoster found?

often found on the face, head, and hair covered body areas

where is seborrheic dermatitis located?

on the palms, soles, and nail beds in African Americans than in other groups

where is skin cancer most common?

they have a lesser ability of secreted sebum to travel along the hair shaft from the skin

why is African American hair more coarse that Caucasians?

responsible for some melanomas, effects of photoaging, specifically wrinkling and letharging of the skin

UVA

more likely to cause sunburn, and are directly linked with skin cancer

UVB

D) Psoriasis

14. Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the APRN notes the area to be a reddish-pink lesion covered with silvery scales. What would the APRN chart? A) Seborrhea B) Contact dermatitis C) Eczema D) Psoriasis

A) Renal failure

15. The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the patient's hairline. What would this indicate to the nurse? A) Renal failure B) Cardiovascular failure C) Hepatic failure D) Respiratory failure

A) The patient exhibits no signs or symptoms of infection

16. The nurse is caring for a patient with a nursing diagnosis of impaired skin integrity related to a stage III decubitus ulcer. What would be the most important outcome for this patient? A) The patient exhibits no signs or symptoms of infection B) The patient changes position every 2 hours C) The patient keeps the area clean and dry D) The patient knows prevention measures for decubitus

B) Candida

17. An obese 34-year-old man is undergoing a preoperative examination prior to having bariatric surgery. The patient tells the nurse that he has a red sore in his groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse suspect? A) Roseola B) Candida C) Pityriasis rosea D) Herpes simplex

B) Location D) Size E) Texture

18. An 84-year-old woman is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the patient's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) A) Depth B) Location C) Other lesions on body D) Size E) Texture

B) A hematologic problem C) Certain infections E) A coagulopathy

19. As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or preschool-aged child? (Select all that apply.) A) Osteomyelitis B) A hematologic problem C) Certain infections D) Inappropriate play companions E) A coagulopathy

melasma in pregnancy

African American women have increased incidences of what in the skin?

A) Lymphatic vessels D) Blood vessels E) Sweat glands

1. A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.) A) Lymphatic vessels B) Connective tissue C) Vernix D) Blood vessels E) Sweat glands

C) Impetigo

10. A 6-year-old girl is brought to the pediatric clinic by her mother, who tells the APRN that her daughter has a sore on her leg that "just keeps getting bigger." On examination, the APRN notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the APRN tell the mother the lesion is? A) Varicella B) Scabies C) Impetigo D) Rubella

D) will usually resolve by age 9 years

11. A newborn has a hemangioma on the face. What would be important for the nurse to include in patient teaching? A) Will need surgery to remove B) Will become smaller over the first year of life C) Is made of epithelial cells that form caverns and fill with blood D) will usually resolve by age 9 years

A) Abnormal endocrine function

12. A 63-year-old patient hospitalized with pancreatitis is having problems performing ADLs. The nurse's aide brushes the patient's hair and tells the nurse that the patient is losing an excessive amount of hair. The hair has the hair bulb intact. What might this indicate to the nurse? A) Abnormal endocrine function B) Abnormal ovarian function C) Abnormal hepatic function D) Abnormal integumentary function

B) Arterial ulcer

13. An 81-year-old man presents at the clinic with a painful ulcer on the left big toe. The patient states that the ulcer is very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent, the base of the lesion is ruddy in appearance and exhibits signs of infection. What would the nurse suspect? A) Infected spider bite B) Arterial ulcer C) Infected tick bite D) Venous ulcer

B) Assists in friction protection

2. The physiology instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students? A) Assists in keeping the skin intact B) Assists in friction protection C) Assists in protection from infection D) Assists in keeping skin dry

C) Acne is caused by the impedance of sebum secretion onto the skin's surface

20. A woman and her 14-year-old boy have come to the clinic. The boy has acne lesions and says that he cannot control them. The mother asks the nurse what causes acne. What would be the nurse's best response? A) Acne is caused by the apocrine glands B) Acne is caused by decreased activity of the sebaceous glands C) Acne is caused by the impedance of sebum secretion onto the skin's surface D) Acne is caused by enlarged epocrine glands

C) The patient may experience photosensitivity

3. A patient has been prescribed tetracycline for acne. What is the most important point the nurse should make in patient teaching about this medication? A) The patient may experience phototoxicity B) The medication may interfere with the menstrual cycle C) The patient may experience photosensitivity D) The medication may be inactivated by antacids

B) Ovarian dysfunction

4. A 17-year-old Hispanic teen comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growing on her shoulders and back; the patient also reports that hair is growing on her upper inner thighs. What would the nurse suspect? A) Endocrine disorder B) Ovarian dysfunction C) Hepatic dysfunction D) Chronic nephrosis

B) Signs and symptoms of melanoma

5. The nurse in the dermatology clinic is assessing a 39-year-old woman who has presented at the clinic with a lesion on her left inner thigh. The patient tells the nurse that she discovered the lesion one month ago and has noticed no changes in the color or size of the lesion. What would be the most appropriate teaching subject for this patient? A) Skin self-examination B) Signs and symptoms of melanoma C) Recognizing different types of lesions D) Protection from sun damage

C) "This may be normal in infants."

6. A first-time mother calls the clinic to talk to the nurse. The mother is very upset, saying that her newborn's fingernails dip in the middle, appearing spoon-like. What would be the nurse's best response? A) "Take the baby to the emergency room to be evaluated." B) "Bring your baby to the clinic immediately." C) "This may be normal in infants." D) "This is a sign of a nutritional deficiency. What are you feeding your infant?"

D) Pinch a fold of skin on the patient's forearm

7. A pediatric nurse is doing her initial shift assessments on assigned patients. One of the patient's is a toddler with pneumonia. How would the nurse assess this patient's skin turgor? A) Pinch a fold of skin on the patient's abdomen B) Pinch a fold of skin on the patient's cheek C) Pinch a fold of skin on the patient's upper thigh D) Pinch a fold of skin on the patient's forearm

A) Color B) Condition of hair shaft E) Hair shafts that are shiny

8. When inspecting the hair, what would the nurse note? (Select all that apply.) A) Color B) Condition of hair shaft C) Length of hair D) Hair breakage of more than 6 hairs E) Hair shafts that are shiny

B) The patient's integumentary system is within normal limits

9. The nurse is performing a generalized assessment of a 79-year-old man who has come to the clinic for his annual physical examination. The nurse notes that the patient's skin is thin and rough with abrasions. The patient tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger." When asked if he has any other problems, the patient says that he always seems to be cold. How would the nurse note these findings in the patient's medical record? A) The patient has abnormal thinning of skin B) The patient's integumentary system is within normal limits C) The patient states that wounds are taking longer to heal D) The patient has an abnormal inability to maintain temperature

infectious skin disorders, such as measles, rubella, and varicella

what do fever and chills often accompany?

mumps and meningitis

what do headaches often accompany?

color, texture, moisture, turgor, and temp

what does a general skin assessment include?

Braden Scale. it scores patients from 1 to 4 in each of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction

What tool do you use to assess the skin?

facilitates communication, accurate assessment, and necessary patient education.

becoming familiar with different cultural practices does what?

severe (blistering) sunburn during childhood or adolescence

melanoma on the trunk, arms or legs is associated with what?

rates patients from 1 to 4 in each o 5 subscales: physical condition, mental condition, activity, mobility, and incontinence. a score of less than 14 indicates a high risk of pressure ulcers

describe the norton scale

they are at risk for hypothermia

babies

acne, warts, nevi, insect bites, or early varicella

papular lesions may indicate what?

vasoconstriction, platelet aggregation, and release of thromboplastin promote hemostasis. An inflammatory reaction follows, initially through polymorphonuclear cells to cleanse the wound of debris and kill bacteria. Mononuclear cells follow and become macrophages to further cleanse the wound of debris, dead bacteria, and spent neutrophils.

describe the inflammatory wound classification phase

dark leathery appearance

describe brawny

they rub a coin or other objects across the skin in a specific manner to treat various health concerns

describe coining.

involves placement of a cup on the skin surface, and then applying heat to form a vacuum

describe cupping.

paleness

describe pallor.

Pruritus frequently precedes atopic lesions but follows inflammatory lesions. Recent pruritus may indicate toxic exposure, insect bites, parasite infestations, or viral exanthems such as varicella. Localized pruritus may indicate infestation, insect bite, allergic reaction, or toxic exposure. Generalized pruritus is common in medication or food allergies. Severe pruritus interfering with sleep is frequently from scabies. Psoriasis is occasionally pruritic. Moles usually do not itch. Noting what, if any, remedies the patient tried and their effectiveness may help identify cause.

describe pruritus

Fibroblasts migrate into the wound bed to deposit collagen and secrete growth factors. Macrophages now produce enzymes to stimulate tissue growth and generate blood vessels. The wound bed has the appearance of granulation. As the wound bed continues to regenerate, the wound edges begin to contract and move centrally to close the defect. Finally, epithelial regrowth closes the defect.

describe the proliferation phase of wound classification

Once deposition of new collagen is maximized (at approximately 3 weeks), macrophages stimulate a gradual replacement of the new, rapidly replaced collagen with mature collagen, which greatly increases the tensile strength of the wound.

describe the remodeling phase of wound classification

a whitish coating noted with severe kidney failure

describe uremic frost

control the bleeding and manage the wounds with colleagues

how do you treat large lacerations?

2-3 days because it increases the loss of skin oils

how often do elderly patients need to bathe, and why?

ecchymosis, pressure point, or tinea versicolor

macular lesions may indicate what?

herpes simplex, varicella, or impetigo

vesicular lesions may indicate what?

maculae, papules, nodules, tumors, polyps, wheals, blisters, cysts, pustules, vesicles, and abscesses

what are examples of primary lesions?

Mongolian spots

what are fairly common in African American new borns?

if a patient is scratching a deep, pink, scaly

what are signs of an atopic illness?

keloid formation, traction alopecia, and pseudofolliculitis barbae

what are some common integumentary findings in African Americans?

follow primary lesions, and include scar tissues, crust from dried burns

what are some examples of secondary lesions?

infection, inflammation, infestation, growths, tumors, trauma, and ulcers

what are some examples of unexpected skin findings

increased wrinkling, yellowing, leathery texture, atrophy, and uneven pigmentation

what are the effects of sun damage in older adults?

decreased resilience, sagging and wrinkling of skin structures, and increased visibility and fragility of superficial vascular structures.

what are the effects of thinner skin?

rougher skin texture and prolonged time for wound healing which causes an increase in hypothermia and increased risk for heat stroke

what are the results of a decreased epidermis production?

size color texture shape onset of itching and bleeding nonhealing wounds

what changes in a mole should warrant further evaluation?

a localized injury to the skin and or underlying tissue usually over a bony prominence, as a result of pressure or pressure with a combination of shear and/or friction.

what defines a pressure ulcer?