Podcast
Questions and Answers
When collecting subjective data related to skin health, which question would directly assess a patient's risk factors for melanoma?
When collecting subjective data related to skin health, which question would directly assess a patient's risk factors for melanoma?
- Have you ever been diagnosed with eczema or psoriasis?
- Do you use sunscreen with an SPF of 30 or higher daily?
- Do you have any first-degree family members with a history of melanoma? (correct)
- How often do you moisturize your skin?
A patient reports a change in a mole's characteristics. Which specific changes should the nurse prioritize for further investigation regarding potential malignancy?
A patient reports a change in a mole's characteristics. Which specific changes should the nurse prioritize for further investigation regarding potential malignancy?
- Changes in itching, bleeding, color, size, or borders of the mole. (correct)
- Symmetrical growth of the mole.
- Changes in hair growth within the mole.
- The mole has become raised.
A patient with a history of allergies is being assessed for skin conditions. Besides medications, which of the following allergens should the nurse specifically ask about?
A patient with a history of allergies is being assessed for skin conditions. Besides medications, which of the following allergens should the nurse specifically ask about?
- Pet dander and mold.
- Seasonal fruits and vegetables.
- Dust mites and pollen.
- Latex, nuts, and bees. (correct)
When assessing a patient's risk for skin breakdown, which pre-existing condition would be most important for the nurse to consider?
When assessing a patient's risk for skin breakdown, which pre-existing condition would be most important for the nurse to consider?
During the objective data collection process for a skin assessment, which piece of equipment is essential for evaluating the characteristics of skin lesions?
During the objective data collection process for a skin assessment, which piece of equipment is essential for evaluating the characteristics of skin lesions?
A nurse is beginning a skin assessment. What is the most appropriate initial step in this process?
A nurse is beginning a skin assessment. What is the most appropriate initial step in this process?
During a skin assessment, a nurse observes that a patient has hypopigmented palms and soles. What should the nurse consider as a possible interpretation of this finding?
During a skin assessment, a nurse observes that a patient has hypopigmented palms and soles. What should the nurse consider as a possible interpretation of this finding?
A nurse identifies a ring-like, circular lesion on a patient's skin. How would the nurse document the configuration of this lesion?
A nurse identifies a ring-like, circular lesion on a patient's skin. How would the nurse document the configuration of this lesion?
A patient presents with a skin lesion that appears to be curving in a snake-like pattern. Which term best describes this configuration?
A patient presents with a skin lesion that appears to be curving in a snake-like pattern. Which term best describes this configuration?
A nurse notes that a patient's skin lesions are distributed across the entire back without any discernible pattern. How should the nurse document this distribution pattern?
A nurse notes that a patient's skin lesions are distributed across the entire back without any discernible pattern. How should the nurse document this distribution pattern?
During a skin assessment, the nurse observes small, marked points or dots on the skin. Which term accurately describes this type of lesion?
During a skin assessment, the nurse observes small, marked points or dots on the skin. Which term accurately describes this type of lesion?
When assessing the distribution pattern of skin lesions, the nurse finds that they appear equally on both sides of the body. Which descriptive term is most accurate for this distribution?
When assessing the distribution pattern of skin lesions, the nurse finds that they appear equally on both sides of the body. Which descriptive term is most accurate for this distribution?
A nurse is differentiating between primary and secondary skin lesions. Which characteristic is exclusive to primary lesions?
A nurse is differentiating between primary and secondary skin lesions. Which characteristic is exclusive to primary lesions?
A patient has a lesion that developed from prolonged scratching of a primary skin condition. How should the nurse classify this lesion?
A patient has a lesion that developed from prolonged scratching of a primary skin condition. How should the nurse classify this lesion?
A nurse observes a small, flat, circumscribed area on a patient's skin that is a different color than the surrounding area. What is the most appropriate term to document this?
A nurse observes a small, flat, circumscribed area on a patient's skin that is a different color than the surrounding area. What is the most appropriate term to document this?
A nurse palpates an elevated, solid lesion on a patient's skin. The lesion is less than 1 cm in diameter. Which term should the nurse use to document this finding?
A nurse palpates an elevated, solid lesion on a patient's skin. The lesion is less than 1 cm in diameter. Which term should the nurse use to document this finding?
When assessing a patient, the nurse observes a large, elevated, solid lesion that is greater than 1 cm in diameter. Which term is most accurate to describe this lesion?
When assessing a patient, the nurse observes a large, elevated, solid lesion that is greater than 1 cm in diameter. Which term is most accurate to describe this lesion?
A nurse observes a fluid-filled lesion on a patient's skin that is less than 1 cm in diameter. What is the correct term to describe this type of lesion?
A nurse observes a fluid-filled lesion on a patient's skin that is less than 1 cm in diameter. What is the correct term to describe this type of lesion?
A patient presents with a loss of the epidermis, revealing a shallow, moist area. Which type of secondary skin lesion is this?
A patient presents with a loss of the epidermis, revealing a shallow, moist area. Which type of secondary skin lesion is this?
A nurse assesses a patient and notes dried secretions on a skin lesion. How should the nurse document this finding?
A nurse assesses a patient and notes dried secretions on a skin lesion. How should the nurse document this finding?
During a skin assessment, the nurse observes a lesion with a linear crack extending into the dermis. Which term should the nurse use to document this finding?
During a skin assessment, the nurse observes a lesion with a linear crack extending into the dermis. Which term should the nurse use to document this finding?
What defining characteristic differentiates a lipoma from other skin tumors?
What defining characteristic differentiates a lipoma from other skin tumors?
A nurse is assessing a patient with suspected squamous cell carcinoma. What characteristic of the lesion should the nurse expect?
A nurse is assessing a patient with suspected squamous cell carcinoma. What characteristic of the lesion should the nurse expect?
Which of the following is a distinguishing feature of basal cell carcinoma?
Which of the following is a distinguishing feature of basal cell carcinoma?
When assessing skin lesions, what is the most critical action for the nurse to take after identifying a wound or incision?
When assessing skin lesions, what is the most critical action for the nurse to take after identifying a wound or incision?
In a hospitalized patient, which assessment finding is most indicative of the need to identify the risk for skin breakdown?
In a hospitalized patient, which assessment finding is most indicative of the need to identify the risk for skin breakdown?
Which aspect of a wound should the nurse assess to determine if it is partial- or full-thickness?
Which aspect of a wound should the nurse assess to determine if it is partial- or full-thickness?
What is a key assessment finding related to fingernails that should be considered a normal variant, especially in aging patients?
What is a key assessment finding related to fingernails that should be considered a normal variant, especially in aging patients?
During a nail assessment, the nurse observes transverse and longitudinal concavity of the nail, giving it a spoon-like appearance, Which condition is most likely?
During a nail assessment, the nurse observes transverse and longitudinal concavity of the nail, giving it a spoon-like appearance, Which condition is most likely?
Which condition can result in slowed or halted nail growth in response to illness, physical trauma, or poisoning?
Which condition can result in slowed or halted nail growth in response to illness, physical trauma, or poisoning?
When assessing the scalp, which characteristic of hair distribution is considered normal?
When assessing the scalp, which characteristic of hair distribution is considered normal?
A patient presents with noninflammatory hair loss in a circumscribed distribution. Which condition is likely causing this?
A patient presents with noninflammatory hair loss in a circumscribed distribution. Which condition is likely causing this?
A nurse is assessing a patient's skin during a physical exam. Which part of the hand should the nurse use to best assess the patient's skin temperature?
A nurse is assessing a patient's skin during a physical exam. Which part of the hand should the nurse use to best assess the patient's skin temperature?
Which technique is used to assess skin turgor, an indicator of hydration status?
Which technique is used to assess skin turgor, an indicator of hydration status?
What observation indicates normal skin vascularity when direct pressure is applied and then released?
What observation indicates normal skin vascularity when direct pressure is applied and then released?
When performing a hair pull test, how many hairs should the nurse grasp to assess hair loss effectively?
When performing a hair pull test, how many hairs should the nurse grasp to assess hair loss effectively?
Which statement accurately reflects a normal finding that should be documented following a skin assessment?
Which statement accurately reflects a normal finding that should be documented following a skin assessment?
Documentation of hair assessment findings should include which characteristic to indicate normal hydration status?
Documentation of hair assessment findings should include which characteristic to indicate normal hydration status?
A patient reports that several moles on their body have a snake-like curving pattern. How should the nurse document this finding?
A patient reports that several moles on their body have a snake-like curving pattern. How should the nurse document this finding?
A nurse is assessing a new skin lesion and observes that it has a central depression. Which term accurately describes this characteristic?
A nurse is assessing a new skin lesion and observes that it has a central depression. Which term accurately describes this characteristic?
During a skin assessment, the nurse notes that a patient's skin is cool and clammy. Which action should the nurse take next to determine the underlying cause?
During a skin assessment, the nurse notes that a patient's skin is cool and clammy. Which action should the nurse take next to determine the underlying cause?
The nurse observes Beau's lines on a patient's fingernails. Which question is most important to include in the patient's history?
The nurse observes Beau's lines on a patient's fingernails. Which question is most important to include in the patient's history?
Upon inspecting a patient's scalp, a nurse finds that the hair is not equally distributed and identifies areas with noninflammatory hair loss. What condition is most likely causing this?
Upon inspecting a patient's scalp, a nurse finds that the hair is not equally distributed and identifies areas with noninflammatory hair loss. What condition is most likely causing this?
Flashcards
What is Inspection?
What is Inspection?
Visual examination of the body, looking for specific characteristics and comparing them to what is considered normal.
What is Palpation?
What is Palpation?
Using touch to assess characteristics such as texture, temperature, moisture, and underlying structures.
What is ABCDE assessment?
What is ABCDE assessment?
Helps identify changes in moles that could indicate skin cancer. It assesses asymmetry, border irregularity, color variation, diameter, and evolution.
What is an Annular lesion?
What is an Annular lesion?
Signup and view all the flashcards
What is an Arciform lesion?
What is an Arciform lesion?
Signup and view all the flashcards
What is a Linear lesion?
What is a Linear lesion?
Signup and view all the flashcards
What is a Polymorphous lesion?
What is a Polymorphous lesion?
Signup and view all the flashcards
What is a Serpiginous lesion?
What is a Serpiginous lesion?
Signup and view all the flashcards
What is a Nummular/Discoid lesion?
What is a Nummular/Discoid lesion?
Signup and view all the flashcards
What is an Umbilicated lesion?
What is an Umbilicated lesion?
Signup and view all the flashcards
What is a Punctuate lesion?
What is a Punctuate lesion?
Signup and view all the flashcards
What is a Filiform lesion?
What is a Filiform lesion?
Signup and view all the flashcards
What is an Asymmetric lesion distribution?
What is an Asymmetric lesion distribution?
Signup and view all the flashcards
What is a Diffuse lesion distribution?
What is a Diffuse lesion distribution?
Signup and view all the flashcards
What is a Localized lesion distribution?
What is a Localized lesion distribution?
Signup and view all the flashcards
What is a Symmetric lesion distribution?
What is a Symmetric lesion distribution?
Signup and view all the flashcards
What is a Generalized lesion distribution?
What is a Generalized lesion distribution?
Signup and view all the flashcards
What is a Zosteriform lesion distribution?
What is a Zosteriform lesion distribution?
Signup and view all the flashcards
What are Primary skin lesions?
What are Primary skin lesions?
Signup and view all the flashcards
What are Secondary skin lesions?
What are Secondary skin lesions?
Signup and view all the flashcards
What is a Macule?
What is a Macule?
Signup and view all the flashcards
What is a Papule?
What is a Papule?
Signup and view all the flashcards
What is a Patch?
What is a Patch?
Signup and view all the flashcards
What is a Plaque?
What is a Plaque?
Signup and view all the flashcards
What is a Nodule?
What is a Nodule?
Signup and view all the flashcards
What is a Vesicle?
What is a Vesicle?
Signup and view all the flashcards
What is a Bulla?
What is a Bulla?
Signup and view all the flashcards
What is an Ulcer?
What is an Ulcer?
Signup and view all the flashcards
What is a Crust?
What is a Crust?
Signup and view all the flashcards
What is an Atrophy lesion?
What is an Atrophy lesion?
Signup and view all the flashcards
What is a Scar lesion?
What is a Scar lesion?
Signup and view all the flashcards
What is an Erosion lesion?
What is an Erosion lesion?
Signup and view all the flashcards
What is Fissure lesion?
What is Fissure lesion?
Signup and view all the flashcards
What is a Lipoma?
What is a Lipoma?
Signup and view all the flashcards
What is a Lentigo?
What is a Lentigo?
Signup and view all the flashcards
What is Squamous Cell Carcinoma?
What is Squamous Cell Carcinoma?
Signup and view all the flashcards
What is Kaposi Sarcoma?
What is Kaposi Sarcoma?
Signup and view all the flashcards
What is Basal Cell Carcinoma?
What is Basal Cell Carcinoma?
Signup and view all the flashcards
What assess with dorsal hand surface?
What assess with dorsal hand surface?
Signup and view all the flashcards
What assess with palmar finger surface?
What assess with palmar finger surface?
Signup and view all the flashcards
What is Koilonychia linked to?
What is Koilonychia linked to?
Signup and view all the flashcards
What is Longitudinal Ridging linked to?
What is Longitudinal Ridging linked to?
Signup and view all the flashcards
What are Beau's Lines linked to?
What are Beau's Lines linked to?
Signup and view all the flashcards
What is Alopecia Areata?
What is Alopecia Areata?
Signup and view all the flashcards
Study Notes
Skin, Nail, Hair Assessment Overview
- This lecture covers the assessment of skin, nails, and hair.
- It includes subjective and objective data collection and the documentation of normal findings.
- The techniques of inspection and palpation are also covered.
Subjective Data Collection: History and Risks
- Questions are asked to assess the patient's history and risk factors related to skin conditions.
- Family history inquiries involve first-degree relatives with melanoma and the presence of multiple dark, irregular moles.
- Past history questions concern skin self-examination frequency and the date of the last clinical skin examination.
- Other questions involve skin lesions, sunburns, skin cancer, organ transplants, HIV/AIDS, chemotherapy, and radiation therapy.
- Medication questions include current medications, allergies, and reactions to allergies and sunscreen.
- Assess lifestyle, occupational history, and personal behaviors related to sun exposure and radiation.
- Determine the risk for skin breakdown and inquire about diabetes mellitus, peripheral vascular disease, and sensory loss.
Objective Data Collection: Equipment
- Necessary equipment includes an examination gown, tape measure, adequate light source, and magnifying glass.
Techniques: Inspection - Skin
- Visually examine all body areas, starting with the head and progressing to the feet.
- Part hair to visualize the scalp.
- Separate the toes to assess the skin.
- Note the general skin color.
- Normal findings include consistent body pigmentation and hypopigmented palms and soles(in dark-skinned patients).
- During inspection, look for lesions and identify the morphology, configuration, distribution pattern, size, and exact location.
- Common benign lesions include freckles, birthmarks, skin tags, moles, and cherry angiomas.
- Lesion configurations include annular, arciform, and linear shapes, as well as polymorphous, serpiginous, nummular/discoid, umbilicated, punctuate, and filiform arrangements.
- Distribution patterns are categorized as asymmetric, diffuse, localized, symmetric, discrete, grouped, and confluent.
Primary and Secondary Skin Lesions
- Primary skin lesions are present at the onset of a disease.
- They develop as a consequence of the disease process.
- Secondary skin lesions evolves over time.
- Or they are a result of manipulation/treatment of primary lesions, or consequences of the patient's activities.
- Examples of primary skin lesions include macules, papules, patches, plaques, nodules, vesicles, and bullae.
- Examples of secondary skin lesions include ulcers, crusts, atrophy, scars, erosions, and fissures.
Skin Tumors and Growths
- Tumors can be lipomas (fatty tumors) or Lentigines that are benign macules found on sun-exposed skin.
- Skin cancers include squamous cell carcinoma, Kaposi sarcoma, and basal cell carcinoma.
- Lesions can be papular, nodular, or plaques.
Techniques: Inspection - Infections and Wounds
- Identify infections using infection-control standards.
- Note any inflammatory lesions.
- Any growths, tumors, or vascular abnormalities present look out for.
- Inspect wounds or incisions, and describe measure length, width, and depth, and tunnel.
- For trauma-related wounds, assess blood supply and note any bleeding or ecchymosis.
- Assess risk for skin breakdown and pressure areas.
- Classify the wound and identify the stage if it is a pressure ulcer.
- Observe and document size, depth, margins, and condition of surrounding tissues.
- Also observe any drainage, odor, or necrotic tissue.
Techniques: Inspection - Nails
- Inspect each fingernail and toenail for color, thickness, and consistency.
- Nails should be smooth, translucent, and consistent in color and thickness.
- Longitudinal ridging can occur in aging patients, and pigmentation is normal in dark-skinned patients.
- Assess the nail angle by having the patient place fingernails together.
Nail Abnormalities
- Spoon nails and pitted marks are some abnormalities
- Yellow nails mean something may be wrong
Techniques: Inspection - Hair
- Inspect the hair for color, consistency, distribution, hair loss, and shaft condition.
- Hair should be symmetrically distributed across the scalp.
- Lesions or color changes should be noted, and scalp skin should be consistent in color with the body.
Other Abnormalities
- Alopecia areata can inflame the distribution, in noncontinuous areas
Techniques: Palpation - Skin
- Assess skin temperature using the dorsal surface of the hands.
- Use the palmar surface of the fingers and hands to assess moisture and texture.
- This should be consistently smooth throughout
- Finally, assess skin turgor.
- Skin should easily go back to the original position
Techniques: Palpation - Assessing
- To properly assess pressure apply fingers and check the colour
- Asses smoothness
- Hair should come out but only a little
Documentation of Normal Findings
- Document subjective and objective findings, including the absence of pruritus, skin lesions, and excessive dryness.
- Skin should have even color with good texture, with intact turgor and no lesions.
- Hair texture should be smooth texture and symmetrical distributed
- Nails should be smooth and translucent, with consistent colour.
- Ensure to note any areas of pigmentation and any lesions on the body.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.