Podcast
Questions and Answers
Which intervention is most appropriate for a patient presenting with an itchy rash?
Which intervention is most appropriate for a patient presenting with an itchy rash?
What is the correct use of ice packs or cold therapy for injuries?
What is the correct use of ice packs or cold therapy for injuries?
Which characteristic of a mole raises the most concern according to the ABCDE mnemonic?
Which characteristic of a mole raises the most concern according to the ABCDE mnemonic?
What action should be prioritized when a suspicious mole is identified?
What action should be prioritized when a suspicious mole is identified?
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What is a common change in the hair of older adults?
What is a common change in the hair of older adults?
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What nail condition is indicated by a nail bed angle greater than 180 degrees?
What nail condition is indicated by a nail bed angle greater than 180 degrees?
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Which factor is NOT a risk for dehydration?
Which factor is NOT a risk for dehydration?
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When assessing a rash, what should be included in the assessment process?
When assessing a rash, what should be included in the assessment process?
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Daily sunscreen use is important because it:
Daily sunscreen use is important because it:
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Which condition could lead to an increased risk of onychomycosis in older adults?
Which condition could lead to an increased risk of onychomycosis in older adults?
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Which method is utilized to assess skin turgor effectively?
Which method is utilized to assess skin turgor effectively?
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What does a Braden Scale score of 23 indicate?
What does a Braden Scale score of 23 indicate?
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Which of the following skin lesions is characterized by large, fluid-filled blisters?
Which of the following skin lesions is characterized by large, fluid-filled blisters?
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For high-risk patients, how often should repositioning occur while in bed to prevent pressure injuries?
For high-risk patients, how often should repositioning occur while in bed to prevent pressure injuries?
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Which stage of pressure injury involves muscle or bone with tunneling and undermining?
Which stage of pressure injury involves muscle or bone with tunneling and undermining?
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What is the key characteristic of wheals in dermatological assessment?
What is the key characteristic of wheals in dermatological assessment?
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What should be avoided on bony prominences to prevent skin breakdown?
What should be avoided on bony prominences to prevent skin breakdown?
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Which of the following best describes macules?
Which of the following best describes macules?
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What type of skin lesions are papules identified as?
What type of skin lesions are papules identified as?
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Which intervention is considered the BEST for patients at high risk for pressure injuries?
Which intervention is considered the BEST for patients at high risk for pressure injuries?
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What is the recommended nursing intervention for managing an itchy rash?
What is the recommended nursing intervention for managing an itchy rash?
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Which of the following characteristics of a mole is NOT part of the ABCDE mnemonic?
Which of the following characteristics of a mole is NOT part of the ABCDE mnemonic?
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In older adults, what is a common change observed regarding hair growth?
In older adults, what is a common change observed regarding hair growth?
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What is the significance of documenting interventions for cold therapy applied to a rash?
What is the significance of documenting interventions for cold therapy applied to a rash?
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What is a priority nursing diagnosis related to skin assessment findings?
What is a priority nursing diagnosis related to skin assessment findings?
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What should a nurse educate a patient about daily sunscreen use?
What should a nurse educate a patient about daily sunscreen use?
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Which factor is a risk for chronic nail clubbing?
Which factor is a risk for chronic nail clubbing?
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Which method is most effective in assessing for dehydration in a patient?
Which method is most effective in assessing for dehydration in a patient?
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When assessing a rash, what specific communication should be prioritized with the patient?
When assessing a rash, what specific communication should be prioritized with the patient?
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Which condition presents with an angle of the nail bed greater than 180 degrees?
Which condition presents with an angle of the nail bed greater than 180 degrees?
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What assessment method is used to evaluate skin turgor in patients?
What assessment method is used to evaluate skin turgor in patients?
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Which stage of a pressure injury is characterized by the absence of deeper tissue involvement?
Which stage of a pressure injury is characterized by the absence of deeper tissue involvement?
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What is the main risk factor for pressure injuries assessed by the Braden Scale?
What is the main risk factor for pressure injuries assessed by the Braden Scale?
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Which intervention is least effective for preventing pressure injuries in high-risk patients?
Which intervention is least effective for preventing pressure injuries in high-risk patients?
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Which type of skin lesion is described as small, fluid-filled blisters?
Which type of skin lesion is described as small, fluid-filled blisters?
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What factor is prioritized in assessing elderly patients with hip fractures for pressure injury risk?
What factor is prioritized in assessing elderly patients with hip fractures for pressure injury risk?
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What should NOT be applied on bony prominences to prevent skin breakdown?
What should NOT be applied on bony prominences to prevent skin breakdown?
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What indicates a Braden Scale score of 6?
What indicates a Braden Scale score of 6?
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Which skin change is indicative of eczema?
Which skin change is indicative of eczema?
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How often should weight shifts occur for patients sitting in a chair to prevent pressure injuries?
How often should weight shifts occur for patients sitting in a chair to prevent pressure injuries?
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Study Notes
Skin and Hair Assessment
- When assessing a rash, ask the patient about pain or itching using OLDCARTS.
- Always wear gloves while physically assessing a patient with a rash.
- Family members should also wear gloves if touching a patient with a rash.
- Discourage patients from scratching itchy rashes.
- A cool cloth might soothe an itchy rash.
- Use an ice pack or cold therapy for injury or pain, but do not place it directly on the skin.
- Use a cloth or towel as a barrier when using cold therapy.
- Assess the site of cold therapy every 5-10 minutes for color changes, pain, sensation, blisters, and any other signs of change.
- Document the use of cold therapy, including the duration, skin condition, and patient's tolerance.
- Instruct the patient to report any discomfort or new symptoms related to the site of the cold therapy.
Health Promotion and Skin Lesions
- Educate patients about the importance of daily sunscreen use, even if they do not get burnt.
- Abnormal moles or nevi are the most concerning type of lesions.
- Use the ABCDE mnemonic to assess for abnormal moles:
- Asymmetry: one half of the mole doesn't match the other half.
- Border irregularity: the edges are irregular, blurred, or notched.
- Color variation: the mole has different shades of brown, black, red, or white.
- Diameter greater than 6 mm: the mole is larger than a pencil eraser.
- Evolving or changing: the mole is new, unlike the patient's other moles, or is changing in size, shape, or color.
- Report any suspicious moles to the provider.
- Debriding is a surgical procedure that is not within the nurse's scope.
- Older adults may experience hair thinning or loss on the head and increased hair growth in other areas.
- They are at increased risk for onychomycosis (nail fungus).
Nail Clubbing and Dehydration
- Nail clubbing is a condition where the angle between the fingernail and the nail bed is greater than 180 degrees.
- It is a result of chronic hypoxia, common in chronic lung or heart disease.
- Dehydration is a priority nursing diagnosis, particularly related to circulation.
- Assess for risk factors of dehydration, such as:
- Gastrointestinal losses: vomiting and diarrhea
- Inadequate intake: nausea, poor oral fluid intake, and malnutrition.
- Conditions requiring extra fluids: infection/sepsis, bleeds, fever, etc.
- Assess for signs and symptoms of dehydration:
- Skin tenting (decreased skin turgor - pinch below clavicle to assess).
- Dryness of the skin.
Common Skin Lesions
- Vesicles: are small, fluid-filled blisters seen in Herpes Zoster (shingles) and Herpes Simplex Virus (HSV).
- Bullae: are large, fluid-filled blisters.
- Macules: are small, flat, hypo- or hyper-pigmented areas (cherry angiomas, lentigines/liver spots, birthmarks, etc.).
- Papules: are small, raised, solid lesions.
- Pustules: are pus-filled lesions, usually inflamed, erythematous, and painful.
- Patches: are large macules, usually erythematous, such as in eczema.
- Wheals: are erythematous, raised, swollen lesions (e.g., hives or TB skin test).
Pressure Injuries: Assessment
- The Braden Scale is the best tool to assess risk factors for pressure injuries.
- A score of 6 on the Braden Scale indicates the highest risk, while a score of 23 indicates the lowest risk.
- Factors assessed by the Braden Scale include:
- Immobility.
- Poor nutrition (low serum albumin or protein).
- Friction and shear.
- Sensory impairment.
- Moisture.
- Lack of movement.
- Elderly patients with hip fractures are at an extremely high risk for pressure injuries due to immobility.
- Assess patients upon admission to the hospital, especially those with several risk factors.
-
Staging of Pressure Injuries:
- Stage 1: non-blanchable erythema (no open wound yet).
- Stage 2: superficial ulcer, no involvement of deeper tissues.
- Stage 3: involves subcutaneous tissue, may have tunneling or undermining.
- Stage 4: involves muscle or bone, very deep with tunneling and undermining.
- When evaluating treatment interventions, assess for signs of healing. For example, when evaluating stage 4 healing, assess for muscle/bone involvement.
Pressure Injury Prevention and Treatment
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Keep the skin clean and dry:
- Frequent monitoring and management of incontinence.
- Avoid lotion/ointment on bony prominences.
- Check for incontinence every two hours.
- Cleanse with lukewarm water (NOT HOT WATER).
- Avoid excessive bathing if not indicated.
- Use gentle soap and fully dry the skin as needed.
- Avoid scrubbing the skin and using powders.
- Avoid keeping briefs on for prolonged periods (keeps moisture on the skin).
-
Offload pressure:
- Turn and reposition every two hours (while in bed).
- Use a bed with alternating pressure, heel lift pads, and a turning wedge.
- If the patient is sitting in a chair, shift weight every 15 minutes.
- Keep the head of the bed low to offload pressure on the sacrum/coccyx.
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Maintain adequate hydration status:
- Patients at high risk may need extra protein supplements, especially if they have poor oral intake or low serum albumin or protein.
Skin, Hair, and Nails Assessment
- Always wear gloves during physical assessment for patients with rashes.
- Family members should also wear gloves when touching the patient.
Rash Interventions
- Discourage scratching for itchy rashes.
- Cool cloths may soothe itchy rashes.
- Ice packs/cold therapy can be used for injury/pain.
- Do not place ice packs directly on skin, use a cloth or towel as a barrier.
- Assess the site every 5-10 minutes for color, pain, sensation, blisters, etc.
- Document the intervention, including duration, skin condition, and tolerance.
- Instruct the patient to report any discomfort or new symptoms related to the site.
Health Promotion
- Educate patients on the importance of daily sunscreen use, even if they don't get burnt.
Abnormal Moles/Nevi
- Most concerning type of lesions.
- Use the ABCDE mnemonic to assess moles:
- Asymmetry
- Border irregularity
- Color variation
- Diameter > 6mm
- Evolving or changing
- Report suspicious moles to the provider.
- Debriding is a surgical procedure, not within the scope of nursing practice.
Older Adult Skin Changes
- Hair thinning or loss on the head, may grow hair in other places.
- Increased risk for onychomycosis (nail fungus).
Nail Clubbing
- Nail bed angle greater than 180 degrees.
- Indicates chronic hypoxia (chronic lung or heart disease).
Dehydration
- Priority nursing diagnosis related to circulation.
- Assess for risk factors:
- GI losses: Emesis and diarrhea
- Inadequate intake: Nausea, poor oral fluid intake
- Conditions requiring extra fluids: Infection/sepsis, bleeds, fever, etc.
- Assess for signs and symptoms:
- Skin tenting (decreased skin turgor)
- Dryness of skin
Lesions
- Vesicles: Small fluid-filled blisters; seen in Herpes Zoster & HSV
- Bullae: Large fluid-filled blisters
- Macules: Small flat hypo/hyperpigmented areas (cherry angiomas, lentigines/liver spots, birthmarks, etc.)
- Papules: Small raised solid lesions
- Pustules: Pus-filled lesions, usually inflamed/erythematous/painful
-
Patches: Large macules, usually erythematous such as in eczema
- Eczema: Itchy erythematous patches typically found in the antecubital space.
- Wheals: Erythematous, raised, swollen lesions (e.g., hives or TB skin test)
Pressure Injuries
-
Assessment:
- Braden Scale is the best tool to assess risk factors.
- Score ranging from 6 (highest risk) to 23 (lowest risk)
- Factors include: Immobility, poor nutrition, friction/shear, sensory impairments, moisture, and lack of movement.
- Elderly patients with hip fractures are at high risk due to immobility.
- Assess for risk factors upon hospital admission, especially if the patient has multiple risk factors.
- Braden Scale is the best tool to assess risk factors.
-
Staging:
- Stage 1: Non-blanchable erythema (no open wound yet).
- Stage 2: Superficial ulcer, no involvement of deeper tissues.
- Stage 3: Involves subcutaneous tissue, may have tunneling/undermining.
- Stage 4: Involves muscle or bone, very deep, tunneling & undermining.
-
Treatment Interventions:
- Keep skin clean and dry.
- Frequent monitoring and management of incontinence.
- Avoid lotion/ointment on bony prominences.
- Check for incontinence every two hours.
- Cleanse with lukewarm water (NOT hot water).
- Avoid excessive bathing if not indicated (keep skin dry).
- Use gentle soap and fully dry skin as needed.
- Avoid scrubbing skin and using powders on skin.
- Avoid briefs for prolonged periods (keeps moisture on skin).
-
Prevention:
- The BEST intervention is offloading pressure.
- Turn/reposition every two hours (while in bed).
- Use a bed with alternating pressure, heel lift pads, and turning wedge.
- If the patient is sitting in a chair, shift weight every 15 minutes.
- Keep the head of bed low to offload pressure on the sacrum/coccyx.
- Maintain adequate hydration status.
- The patient may need extra protein supplements, especially if they have poor oral intake or low serum albumin or protein levels.
- The BEST intervention is offloading pressure.
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Description
This quiz focuses on key concepts related to skin and hair assessment, including proper techniques for evaluating rashes and the significance of cold therapy. It also covers health promotion strategies for skin care, emphasizing the importance of sunscreen. Test your knowledge on best practices for patient care in dermatology.
