Chapter 14: Assessing Skin, Hair, Nails

What is the dermis?

thin layer, containing collagen, elastic tissue

Sebaceous gland?

hair follicle, on all body besides palms/sole

eccrine sweat glands?

over skin, normal sweat

apocrine sweat glands?

hair follicles/ perineum

Melanoma:

greatest risk is intermittent sun exposure

Basal Cell Carcinoma:

moderate exposure (trunk/lower legs)

Squamous cell carcinoma:

on body sites most common to heavy sun exposure

What increases the risk for skin cancer?

sun exposure, fair skin, males (>50), HPV, etoh, inadequate niacin in diet.

Pt teaching for protecting against skin cancer:

hates, long sleeves, avoid sun burns, annual cancer screenings

assessing for suspicious skin lesion and warning signs

Asymmetry
Border
Color
Diameter: 1/8-1/4 inch
Elevated
warning signs: bleeding, tender to touch, itching, grows

what type of lighting is best to use when assessing

natural light

pallor

loss of color, cold skin (amenia)

Erythema

skin redness/warmth, on dark skin palpate for warmth

Cyanosis

O2 deficiency, white/blue tinged. dark skin appears blue/dull

Jaundice

yellow skin bc hepatic dysfunction (fix is UV light). normal in newborn 3-4th day of life

Acanthosis Nigrican

linear streak like pattern in dark skin people, suggests DM. roughening of skin on back of neck

Braden Scale:

sensory perception, moisture, activity, mobility, nutrition, friction/shear. 1 is a problem, 3 having no problem

primary vs secondary

...

linear lesion

straight line, scratch

annular

circular lesions

clustered

lesions grouped together- herpes

discrete

individual and distinct ones

confluent- smaller lesions run together to form larger lesionsMacule

freckle. <1 cm

Patch

Vitiligo. >1 cm

Papules

wart. <.5 cm

Plaque

psoriasis. >.5 cm.

Nodule

elevated palpable,

Vesicle/ Bulla

Elevated mass; contains serous fluid (chicken pox)

Wheal

elevated mass with irregular borders (uticaria). hives

pustule

pus filled vesicle (acne)

cyst

encapsulated fluid filled/semisolid in SQ tissue or dermis

Secondary skin lesion:

...

erosion:

scratch mark

ulcer

skin lost past epidermis

scar/fissure

linear crack, chapped lips/athletes foot

purpuric lesion:

cause by blood flowing out of breaks in the vessels. difficult to see in dark skinned people.

petechia

round red or purple macule 1-2 mm; associated. don't blanch. can be caused my meds

purpura

confluent and extensive patch of petechia and ecchymoses. >3 mm. flat, red to purple, macular hemorrhage.

ecchymosis

round or irregular macular lesions seen with trauma. black eye

hematoma:

localized collection of blood- associated with trauma

cherry angioma:

papular and round

spider angioma:

red arteriole lesion of face, arm, neck. (associated with liver dz, pregnancy, vitamin b deficiency)

how to test for turgor

use 2 finger to pinch over clavical

how to test for edema

use thumb to check for swelling or accumulation of fluid

pitting in nails is seen in ______

psoriasis

koilonychia

(spoon shaped nails) seen with trauma, iron deficiency enema, endocrine and cardiac dz's

clubbing of nails

heart failure, because constantly cyanotic

paronychia

local infection

linea nigra

brownish blackish pigment midline abdomen

striae gravidarum

prego stretch marks

chloasma:

pigment in face

spider nevi

lesions with tiny red centers on face, neck, upper chest and arms

in prego, hair and nails ________, but it _______

grow, but its softer and thinner

in prego, pale skin suggests _______

anemia

normal skil color for newborns

pale white with pink, yellow, brown, olive tone, black

normal in newborns:

acrocyanosis (bluish coloring in hands), physiologic jaundice, milia (tiny white bumps on face), erythema toxicum, cafe au lait (brown spots), benign hemangiomas- strawberry marks (red skin marks), mottling when chilled

abnormal findings in newborns:

yellow skin- jaundice in utero. or jaundice within 24 hours of birth means hemolytic dz.
blue skin- cyanosis
pallor- anemia
redness- fever, irritation
6 or more cafe au last can mean neurofibromatosis

tuffs of hair over spine in new borns can mean:

spina bifida

blue nailneds in newborns can mean

cyanosis

mongolian spots

bluish pigmented areas on sacral areas of asians, african americans, and mexican american infants

rubeola

rubella

chickenpox

scaly lesions means

fungal infection

normal variation in adult:

skin tags, skin lesions, more pale bc decreased melanin, dryer bc decreased sebum, wrinkled skin, hair is dryer/thinner. nails are thicker, yellow and brittle.

abnormal findings in adults:

herpes zoster (painful rash), petechiae (platelet deficiency), bruises, purpura, torn skin, patchy, assymetic hair loss.

normal IV site

skin is intact, without redness, swelling, phebitis

report an IV site:

report pain, any redness, sweeping, appearance of vein, cool skin