HA exam 4 chapter 14, skin hair and nails

hirsutism

facial hair on females, characteristic of crushing disease and polycystic ovary syndrome

clubbing of nails

finding in the nails that indicates chronic hypoxia

macule

flat, nonpalpable skin color that may look brown, white, red, tan or purple

senile lentigines

flat, tan brown spots on skin

stage 4 pressure injury

full thickness skin and tissue loss, can see organs or bones (apple core)

stage 3 pressure ulcer description

full thickness skin loss with damage to or necrosis of subcutaneous tissue

stage 3 pressure injury

full thickness skin loss, visible adipose tissue, beefy red color (bite out of an apple)

onychomycosis

fungal infection of the nail

patient with dull dry hair may have

hypothyroid or malnutrition

rough, flakey dry skin is seen in patients with

hypothyroidism, or obese patients

pale or cyanotic nails may indicate

hypoxia or anemia

when would you see a client with sudden hair loss

if they have hypothyroidism or if they are on chemo or radiation therapy

when assessing scalp and hair a patient with raised lesions indicates

infection or tumor

folliculitis

inflammation of the hair follicles, pustules surrounded by erythema

dermatitis

inflammation of the skin

if a patient has a specific concern the nurse should do what in order

inspect the area first then ask questions

fissures

linear cracks in the skin that may extend to the dermis and may be painful

what causes jaundice

liver dysfunction

vitiligo

localized loss of skin pigmentation characterized by milk-white patches

erosion

loss of superficial epidermis that does not extend to the dermis, usually on depressed moist area. ex. canker sore

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

melanoma

less than 2 second recoil skin turgor

moderate dehydration

stage 1 pressure injury

non-blanchable erythema of intact skin, (apple)

unstageable pressure injury

obscured full-thickness skin and tissue loss - yellow base covering injury (carmal apple appearance)

pallor

paleness, be prepared for patient to faint

stage 2 pressure injury

partial thickness skin loss with exposed dermis, looks like a blister (peeled apple)

nutritional deficiencies often cause

patchy grey hair in some clients or clients of african american race hair may turn a copper, red color

deep tissue pressure injury

persistent non-blanchable deep red, maroon, or purple discoloration

braden scale is used for

predicting pressure sore risk

sweating for asians and native americans compared to caucasians

produce less sweat, therefore less body odor

diaphoresis

profuse sweating

plaque lesions

psoriasis

cutaneous tag

raised papule with a depressed center

keloids

raised scar

purpura

rash or purple spots on skin due to blood vessels leaking blood into skin

eczema

redness of the skin caused by swelling of the capillaries - on flexor surface

tinea capitis

ringworm of the scalp, pustules with hair loss in matches

ecchymosis

round or irregular macular lesion that is larger than petechial lesion. color varies and changes: black, yellow and green hues

petechia

round red or purple macule that are small. secondary to blood extraversion and associated with bleeding tendencies or emboli to skin

seborrheic

scaly patches on scalp

skin lesions associated with aging

seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura and cutaneous tags and hornes

braden scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

more than 2 seconds recoil skin turgor

severe dehydration

cold skin is associated with

shock or hypotension

psoriasis

skin rash that is scabbing and crusty with silvery scales, patients also may have "pits" in the nails. - on the extensor surface

erythema

skin redness and warmth, seen in inflammation, allergic reactions or trauma

cherry angiomas

small raised spots (1-5cm wide) typically seen with aging

koilonychia

spoon nails, from iron deficiency, anemia, endocrine or cardiac disease

risk factors for skin cancer

sun, tanning beds, moles and ionizing radiation

a strong odor of perspiration or foul odor may indicate a disorder of what

sweat glands or poor hygeine

mobility

swollen and tight skin, will not be able to check for turgor

example of mobility

swollen tight skin

important function of the skin

synthesis of vitamin D

cause of butterfly rash

systemic lupus erythematosus

carotene

the yellow pigment of the skin, found in subcutaneous fat layer

Acanthosis nigricans

thickening and darkening of the skin in body folds and creases (neck, groin and axilla)

angioma

tumor composed of blood vessels

melanoma

type of skin cancer that can be spread to other organs

wood's light

ultraviolet light used for diagnosing skin conditions

itchy, raised rash that appears and disappears in various location. each lesion last for many minutes

urticaria or hives

vesicular lesion

varicella or herpes

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

wood's light

jaundince

yellow skin, sclera, oral mucosa, palms and soles

distribution of skin lesions charcteristics

" generalized" "exposed surfaces" "upper arm" "skin folds"

squamous cell carcinoma

- Type of skin cancer more serious than basal cell carcinoma; often characterized by scaly red papules or nodules. - most common skin cancer in darker skin

turgor

- decreased turgor seen in dehydration

tinea

- infection of the skin caused by a fungus - ringworm

basal cell carcinoma

- malignant tumor of the basal cell layer of the epidermis - most common skin cancer in caucasians

malignant melanoma

- most serious from of skin cancer - caucasians most at risk

ways to prevent pressure ulcers

- repositioning - sit in chair for 15 min - be in bed for 2 hours - offload heels - low air-loss surface

cutaneous horn

-Usually on face where skin grows faster -Hyperkeratotic papule

spider angioma

-red center with radiating red legs -up to 2 cm -can be raised - associated with liver disease, pregnancy and vitamin B deficiency

hematoma

A localized swelling filled with blood, associated with trauma

scar

A mark on the skin that is left after a cut or other wound has healed.

ABCDE mneonic for abnormal findings for skin cancer

A= asymmetrical B= irregular borders C= color variations D= diameter exceeding 1/8-1/4in E= elevated

ABCDEF meaning

A= sensory perception B= moisture C= activity D= mobility E= nutrition F= friction and shear

albinism

Absence of pigment in the skin, hair, and eyes

clubbing of fingers

Caused by chronic hypoxia. Presence of this is suggestive of pulmonary disease.

hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood

uticaria

Rash notable for pale red, raised, itchy bumps

hives

Red, itchy, possibly raised blotches on the skin that often result from allergic reactions

most important focus area for the integumentary system

UV radiation exposure - exposure has shown to cause skin cancer, particularly melanoma

cyanosis

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood. (bluish tint)

dermatome

a circumscribed thickening of the skin

male pattern baldness

a common hair-loss pattern in men, with the hairline receding from the front to the back until only a horseshoe-shaped area of hair remains in the back and at the temples - is symmetric

increased moisture or diaphoresis may occur with patients with

a fever or hyperthyroidism

warm skin may indicate

a fever or hyperthyroidism

mole (nevus)

a flat or raised tan/brownish marking up to 6mm wide

what is a secondary skin lesion

a skin lesion that emerges from an existing primary lesions ex. keloids that can emerge from site of a healed wound

seborrheic keratosis

a warty or crusty pigmented lesion

pustular lesion

acne

nevus

another name for a mole

Central cyanosis vs peripheral cyanosis

arterial oxygen level: LOW in central, NORMAL in peripheral caused by hypoxia

example of macule

birthmarks and freckles

telangiectasis

bluish or red lesion with varying shape, found on the legs and anterior chest. does not blanch. associated with increased venous pressure

normal, fixed lesions may indicate

cancer

yellow, brownish patches on OLDER client hands indicates

caused by aging of the skin for older adults

example of fissures

chapped lips and athletes foot

systemic lupus erythematosus

chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs

patient that is a heavy smoker and clubbing of fingernails indicates

chronic hypoxia

very thin skin is seen in

clients with arterial insufficiency or those on steroid therapy

pityriasis

dandruff - usually limited to trunk and proximal extremities

thickened nails indicates

decreased circulation

patients with decreased moisture may be

dehydrated or have hypothyroidism

excessive scaliness may indicate

dermatitis

layer of skin that has sweat glands

dermis

a burn patient will not grown hair anymore at burn location because

destruction of hair follicles located in the dermis layer

What causes acanthosis nigricans?

diabetes or obesity

paronychia

diseased state around the nail

skin of a patient with hypothyroidism

dry and rough

a wheal

elevated mass with transient boarders that are irregular