Download NUR 216 Module 4 EXAM 2024: Health Assessment - Skin and Nails and more Exams Nursing in PDF only on Docsity!
NUR 216 Module 4 EXAM 2024 100% CORRECT AZC
HEALTH ASSESSMENT
List five things you need to do prior to beginning the assessment.
- Review the client chart
- Gather needed supplies
- Announces presence to client
- Ensures client privacy
- Performs hand hygiene What techniques are used for a skin assessment? Inspection and palpation What do you inspect during a skin assessment? Color, texture, moisture, and integrity What do you palpate for during a skin assessment? Texture, moisture temperature, mobility, and turgor What tools are needed in preparation for a skin assessment? Strong direct lighting, gloves, penlight, and small centimeter ruler. Epidermis
The surface layer is a combination of dead cells on the outside and live cells on the inside. It takes about a month for cells to move from the inner surface to the outer surface. This is a way the skin constantly renews itself. Dermis The middle layer is composed of connective tissue that is formed by a dense combination of interconnecting collagen and elastic fibers. It contains blood vessels, hair follicles, cutaneous nerve endings, sensory receptors, lymphatics, ans sebaceous and sweat glands. Subcutaneous The innermost layer contains fatty tissue. This layer stores fat for energy and provides insulation for even temperature control. It has a soft cushioning effect that protects the body and gives the skin flexibility over the skeleton beneath. List the functions of skin and nails.
- Protect the inner body parts and organs
- Body temperature regulation through shivering and sweating
- Sensory perception of temperature, touch, and pain
- Excrete waste and toxic substances
- Produce vitamin D Elasticity in the older adult.
- Loses elasticity; skin folds and sags.
- Decreased skin turgor.
- Rash or lesions?
- Medications: prescription and over-the-counter?
- Hair loss?
- Change in nails' shape, color, or brittleness?
- Environmental or occupational hazards?
- Self-care behaviors? What are questions you can ask aging adults to gather subjective data health history questions?
- What changes have you noticed in your skin in past few years?
- Any delay in wound healing?
- Any change in feet: toenails, bunions, wearing shoes?
- Falling: bruises, trauma?
- History of diabetes or peripheral vascular disease? Melanoma in Whites is noted to be ___ times higher than in Blacks and ___ times higher than in Hispanics. 20 4 List four skin conditions that are noted to be specific to Black patients.
- Keloids
- Pigmentary disorders
- Pseudofolliculitis
- Melasma
List variables that influence skin color.
- Emotional states
- Temperature
- Cigarette smoking
- Prolonged elevation/dependent position of extremities
- Prolonged inactivity List expected findings in skin color.
- Combination of melanin (brown) pigments
- Carotene (yellow) pigments
- Underlying vascular bed of blood vessels (red) Hyperpigmentation Occurs when melanin is increased in one area (ex. birthmarks, sun damage, pregnancy changes) Hypopigmentation Occurs when melanin is somewhat decreased, but not completely absent in one area (ex. scars, stretch marks, vitiligo) List unexpected findings in skin color.
- Cyanosis (lack of oxygen to the tissues; bluish skin)
In general, the skin should be smooth and intact. List unexpected findings in skin integrity. Skin lesions (vascular, primary, secondary, malignant) Inspection and documentation of any skin lesion should include ____.
- Color of lesions
- Height of lesions: flat or raised
- Shape of lesions
- Size of lesions: measured in centimetres
- Location of lesions: single area or generalized
- Presence of lesions: note color and odor Vascular Lesions Result of blood leaking from blood vessels into the dermis (trauma, infection, disease process) Petechiae Small pinpoint (1-3mm) reddish-purple spots, caused by infection or trauma Ecchymosis Collection of blood in the dermis greater than 3mm in diameter. Initially reddish-purple, but will change to blue or yellow during healing, caused by trauma
Purpura Collection of petechiae and ecchymosis covering an area, caused by infection or a bleeding disorder Primary Lesions Result of specific triggering agent which causes a change to previously intact skin Macule Flat area of discoloration, less than 1cm. ex. freckle Patch Flat area of discoloration, greater than 1cm. ex. birthmark Papule Elevated solid lesion less than 1cm. ex. mole. Plaque Elevated solid lesion greater than 1cm. ex. psoriasis
Scale Flaky skin. ex. eczema Fissure Linear break in skin surface. ex. too dry or moist skin Erosion Loss of epidermis, moist. ex. ruptured vesicle Ulcer Damage to epidermis and dermis, scarring. ex. pressure injury Potentially Malignant Lesions Changes to the skin surface that can indicate the presence of skin cancer. Hemangiomas Vascular Lesion
- Port-wine stain
- Strawberry mark
- Cavernous hemangioma
Telangiectases Vascular Lesion
- Spider or star angioma
- Venous lake Purpuric Lesions Vascular Lesion
- Petechiae
- Purpura Lesions caused by trauma or abuse Vascular Lesion
- Pattern injury
- Hematoma
- Contusion When completing a skin assessment, what do you do first? Scrutinize the outer skin surface first before concentrating on underlying structures How often should a diabetic patient inspect feet, toenails, and between toes? Daily
+4 = severe, 8mm, prolonged return, greater than 30 seconds What is the ABCDE rule for melanoma? A = Asymmetry - One half is unlike the other half B = Border - irregular, scalloped, or poorly defined C = Color - varies from one side to another (shades of tan, brown, black or sometimes white, red, blue) D = Diameter - greater than 6mm E = Evolving - looks different from the rest or is changing in size, shape, or color Stage I Pressure Ulcer Nonblanchable erythema, skin is still intact. Stage II Pressure Ulcer Partial thickness, skin breakdown of the epidermis and dermis, superficial, red-pink wound bed Stage III Pressure Ulcer Full thickness skin loss, damage to the subcutaneous tissue, deep without exposed muscle or bone Stage IV Pressure Ulcer Full thickness tissue loss, tissue necrosis or damage to muscle, bone, or underlying structures
Unstageable Pressure Ulcer Eschar or slough obscures wound, depth unknown Deep Tissue Injury (DTI) Discoloration but skin intact, damage to underlying tissue. Risk factors for pressure ulcers.
- Elderly-thinning skin and less subq
- Excessive moisture
- Shearing/friction
- Immobility
- Obesity
- Poor nutrition and hydration
- Vascular disease
- Sensory deficits
- Edema
- Chronic disease-DM, HF, CKD Pressure ulcer prevention.
- Wrinkle free linen
- Reposition q2h or more-Shift weight q15min
- <1hr in chair
- HOB <
