Skin, Nail, and Hair Assessment

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Questions and Answers

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?

  • 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?

  • 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?

<p>Diabetes mellitus. (C)</p>
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During the objective data collection process for a skin assessment, which piece of equipment is essential for evaluating the characteristics of skin lesions?

<p>Magnifying glass. (B)</p>
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A nurse is beginning a skin assessment. What is the most appropriate initial step in this process?

<p>Inspecting all body areas, beginning with the head. (B)</p>
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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?

<p>It is a normal variation in patients with dark skin. (A)</p>
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A nurse identifies a ring-like, circular lesion on a patient's skin. How would the nurse document the configuration of this lesion?

<p>Annular. (D)</p>
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A patient presents with a skin lesion that appears to be curving in a snake-like pattern. Which term best describes this configuration?

<p>Serpiginous. (C)</p>
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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?

<p>Diffuse. (C)</p>
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During a skin assessment, the nurse observes small, marked points or dots on the skin. Which term accurately describes this type of lesion?

<p>Punctuate. (D)</p>
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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?

<p>Symmetric. (C)</p>
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A nurse is differentiating between primary and secondary skin lesions. Which characteristic is exclusive to primary lesions?

<p>They are a direct result of the disease process (B)</p>
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A patient has a lesion that developed from prolonged scratching of a primary skin condition. How should the nurse classify this lesion?

<p>A secondary lesion. (A)</p>
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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?

<p>Macule. (A)</p>
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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?

<p>Papule. (C)</p>
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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?

<p>Plaque. (D)</p>
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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?

<p>Vesicle. (A)</p>
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A patient presents with a loss of the epidermis, revealing a shallow, moist area. Which type of secondary skin lesion is this?

<p>Erosion. (C)</p>
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A nurse assesses a patient and notes dried secretions on a skin lesion. How should the nurse document this finding?

<p>Crust. (A)</p>
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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?

<p>Fissure. (D)</p>
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What defining characteristic differentiates a lipoma from other skin tumors?

<p>Its composition of fat cells. (D)</p>
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A nurse is assessing a patient with suspected squamous cell carcinoma. What characteristic of the lesion should the nurse expect?

<p>Association with actinic keratosis. (A)</p>
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Which of the following is a distinguishing feature of basal cell carcinoma?

<p>A rolled, pearly border. (B)</p>
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When assessing skin lesions, what is the most critical action for the nurse to take after identifying a wound or incision?

<p>Note the shape and measure the length, width, and depth. (B)</p>
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In a hospitalized patient, which assessment finding is most indicative of the need to identify the risk for skin breakdown?

<p>Being inactive. (D)</p>
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Which aspect of a wound should the nurse assess to determine if it is partial- or full-thickness?

<p>The stage of the wound. (D)</p>
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What is a key assessment finding related to fingernails that should be considered a normal variant, especially in aging patients?

<p>Longitudinal ridging. (C)</p>
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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?

<p>Koilonychia. (B)</p>
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Which condition can result in slowed or halted nail growth in response to illness, physical trauma, or poisoning?

<p>Beau’s Lines. (B)</p>
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When assessing the scalp, which characteristic of hair distribution is considered normal?

<p>Hair is equally and symmetrically distributed. (D)</p>
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A patient presents with noninflammatory hair loss in a circumscribed distribution. Which condition is likely causing this?

<p>Alopecia Areata. (B)</p>
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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?

<p>The dorsal surface of the hands. (A)</p>
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Which technique is used to assess skin turgor, an indicator of hydration status?

<p>Grasping a fold of the skin and noting how quickly it returns to normal. (A)</p>
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What observation indicates normal skin vascularity when direct pressure is applied and then released?

<p>The color promptly returns to normal. (A)</p>
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When performing a hair pull test, how many hairs should the nurse grasp to assess hair loss effectively?

<p>10 to 12 hairs. (A)</p>
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Which statement accurately reflects a normal finding that should be documented following a skin assessment?

<p>Skin evenly colored, smooth, and consistently warm. (B)</p>
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Documentation of hair assessment findings should include which characteristic to indicate normal hydration status?

<p>Consistent coloration and hydration. (B)</p>
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A patient reports that several moles on their body have a snake-like curving pattern. How should the nurse document this finding?

<p>Serpiginous. (D)</p>
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A nurse is assessing a new skin lesion and observes that it has a central depression. Which term accurately describes this characteristic?

<p>Umbilicated (A)</p>
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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?

<p>Assess the patient's hydration status and vital signs. (C)</p>
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The nurse observes Beau's lines on a patient's fingernails. Which question is most important to include in the patient's history?

<p>Have you experienced any recent illnesses or injuries? (D)</p>
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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?

<p>Alopecia areata (B)</p>
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Flashcards

What is Inspection?

Visual examination of the body, looking for specific characteristics and comparing them to what is considered normal.

What is Palpation?

Using touch to assess characteristics such as texture, temperature, moisture, and underlying structures.

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?

Ring-like shape

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What is an Arciform lesion?

Lesions arranged in partial rings or arcs

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What is a Linear lesion?

A straight line lesion arrangement

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What is a Polymorphous lesion?

Having varied shapes

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What is a Serpiginous lesion?

Lesion that curves like a snake

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What is a Nummular/Discoid lesion?

Coin-shaped, round lesions

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What is an Umbilicated lesion?

Lesions with a central depression

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What is a Punctuate lesion?

Small, marked with points or dots.

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What is a Filiform lesion?

Papilla-like or finger-like projections (similar to tongue papillae)

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What is an Asymmetric lesion distribution?

Distributed solely on one side of the body.

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What is a Diffuse lesion distribution?

Distributed widely across affected area without any pattern

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What is a Localized lesion distribution?

Located at a distinct area.

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What is a Symmetric lesion distribution?

Distributed equally on both sides of body

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What is a Generalized lesion distribution?

Widespread patterned rash with no clustering.

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What is a Zosteriform lesion distribution?

Linear arrangement along a nerve root.

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What are Primary skin lesions?

Skin changes that directly result from the disease process.

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What are Secondary skin lesions?

Skin changes that evolve from primary lesions or external factors like scratching or treatment.

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What is a Macule?

Flat, distinct, discolored area of skin, usually less than 1 cm wide.

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What is a Papule?

Small raised bump that is solid and distinct.

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What is a Patch?

When macules are greater than 1cm

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What is a Plaque?

Solid, raised, flat-topped lesion usually greater than 1 cm in diameter.

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What is a Nodule?

Solid, raised bump that is usually greater than 1 cm in diameter and may be located in the epidermis or dermis.

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What is a Vesicle?

Small fluid-filled blister less than 1 cm in diameter.

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What is a Bulla?

Large fluid-filled blister greater than 1 cm in diameter.

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What is an Ulcer?

Loss of the surface of the skin.

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What is a Crust?

Dried exudate of body fluids that may be yellow, green, brown, or black.

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What is an Atrophy lesion?

Thinning of the skin

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What is a Scar lesion?

Area of fibrotic tissue that replaces normal skin after injury.

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What is an Erosion lesion?

Area of skin where the epidermis is lost

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What is Fissure lesion?

Linear break in the skin surface

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What is a Lipoma?

Benign fatty tumor usually located in the subcutaneous tissue.

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What is a Lentigo?

Small, brown macules, especially on sun-exposed skin

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What is Squamous Cell Carcinoma?

Related to actinic keratosis and sun exposure. Lesions are typically papular, nodular, or plaques

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What is Kaposi Sarcoma?

Caused by impaired immune status (e.g., AIDS).

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What is Basal Cell Carcinoma?

Shiny with a rolled pearly border and typically has small spider veins.

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What assess with dorsal hand surface?

Assess skin temperature

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What assess with palmar finger surface?

Assess moisture and texture

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What is Koilonychia linked to?

Iron deficiency

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What is Longitudinal Ridging linked to?

Inflammation of connective tissue that form proximal and lateral nail folds/cuticle

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What are Beau's Lines linked to?

A nail abnormality that is characterized by sharply defined, transverse depressions in the nail

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What is Alopecia Areata?

Results in a noninflammatory loss of hair in a circumscribed distribution

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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.

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