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HA- CH 11
Health Assessment
| Question | Answer |
|---|---|
| signs of cyanosis for a light skin person | grayish-blkue tones (esp in nail beds, earlobes, lips, mucous membranes, palms and soles) |
| signs of cyanosis for a dark skin person | ashen-gray color most easily seen in the conjuctiva of the eye, oral mucous membrane, and nail beds |
| signs of ecchymosis (bruise) of a light skin person | dark red, purple, yellow, or green color, depending on age of bruise |
| signs of ecchymosis (bruise) of a dark skin person | deeper bluish or black tone, difficult to see unless it occurs in an area of lighter pigmentation |
| signs of erythema for a light skin person | reddish tone with evidence of > skin temp secondary to inflammation |
| signs of erythema for a dark skin person | deeper brown or purple skin tone with evidence of > skin temp secondary to inflammation |
| signs of cyanosis for a light skin person | grayish-blkue tones (esp in nail beds, earlobes, lips, mucous membranes, palms and soles) |
| signs of cyanosis for a dark skin person | ashen-gray color most easily seen in the conjuctiva of the eye, oral mucous membrane, and nail beds |
| signs of ecchymosis (bruise) of a light skin person | dark red, purple, yellow, or green color, depending on age of bruise |
| signs of ecchymosis (bruise) of a dark skin person | deeper bluish or black tone, difficult to see unless it occurs in an area of lighter pigmentation |
| signs of erythema for a light skin person | reddish tone with evidence of > skin temp secondary to inflammation |
| signs of erythema for a dark skin person | deeper brown or purple skin tone with evidence of > skin temp secondary to inflammation |
| signs of jaundice for a light skin person | yellowish color of skin, sclera of eyes, fingernails, palms of hands, and oral mucosa |
| signs of jaundice for a dark skin person | yellowish green color most obviously seen in sclera of eye, palms, and soles |
| signs of pallor in light skin person | pale skin color that may appear white |
| signs of pallor in dark skin person | skin tone will appear lighter than normal. lighter AA skin may be yellowish-brown and darker AA skin may be ashen...specifically evident is a loss of the underlying healthy red tones of skin |
| signs of petechiae in light skin person | lesions appear small, reddish purple pinpoints |
| signs of petechiae in dark skin person | difficult to see; may be evident in the buccal mucosa of the mouth or sclera of the eye |
| signs of a rash in the light skin person | may be visualized as well as felt with light palpation |
| signs of a rash in a dark skin person | not easily seen but may be felt with light palpation |
| signs of a scar in a light skin person | narrow scar line |
| signs of a scar in a dark skin person | frequently has keloid development, resulting in a thickened, raised scar |
| is an inherited disorder characterized by a complete absence of pigmentation. individuals manifest with a pale white skin tone over the entire body surface | hypopigmentation (albinism) |
| > melanin deposition; this may be a sign of endocrine disorder or liver disease | hyperpigmentation |
| ABCDEF for early signs of melanoma | A- asymmetry (not round or oval) B- border (poorly defined or irregular border) C- color (uneven, variegated) D- diameter (usually greater than 6mm) E- elevation (recent change from flat to raised lesion) F- feeling (sensation of itching, tin |
| most adults have ___ to ____ moles scattered on their body | 10-40 moles |
| moles tend to be less than ____mm in size and should be ___ in shape | 5mm.......round or oval with clear borders |
| small, flat hyperpigmented macules that may appear anywhere on the body, particularly on sun-exposed areas of the skin | freckles |
| an area of darker skin pigmentation that is usually brown or tan in color, and typically is present at birth (birthmarks). some of these patches fade, but many do not change over time | patch |
| silver or pink "stretch marks" secondary to weight gain or pregnancy | striae |
| is an acquired condition associated with the development of unpigmented patch or patches; it is thought to be an autoimmune disorders | vitiligo |
| what do you palpate the skin for? (6) | texture, temp, moisture, mobility, turgor, and thickness |
| the skin should be smooth, soft, and intact with an even surface...what is the only exception to this? | calluses on the hands, feet, elbows, and knees |
| skin temp is best evaluated using the ____ . the skin should be ____ | dorsal aspect of your hands.....warm |
| cool or cold skin may be a sign of ___, _____, or _____ | shock, hypothermia, and hypothyroidism |
| skin is normally ___ | dry |
| excessive sweating | diaphoresis |
| excessive moist skin could be a result of ___ | hyperthyroidism |
| skin that slowly recedes back into place during a turgor test | tenting skin |
| why may < turgor occur? | dehydration, significant weight loss |
| skin starts to decrease in thickness after the age of ___ | 20 |
| where is the skin thickest? | palms of hands and soles of feet |
| where is skin the thinnest? | eyelids |
| what causes skin thickness is DM patients? | abnmormal collagen caused by hyperglycemia |
| hyperthyroidism and arterial insufficiency are disorders associated with _____ | thinning of the skin |
| any observable change from normal skin structure | lesion |
| a yellow-green or blue-green fluorescence lesion indicated the presence of a _____ | fungal infection |
| what are the main characteristics to be noted when looking at a lesion? | location, distribution, color, pattern, edges, (flat, raised, or sunken), size, characteristics |
| what are the 4 techniques for assessment? | inspection, palpation, precusion, and oscultate |
| what are the 4 lesion shapes? | round/oval, annular, iris, gyrate |
| lesion shape: solid appearance with NO central clearing | round/oval |
| lesion shape: round with central clearing (tinea corporis) | annular |
| lesion shape: pink macule with purple concentric ring (erythema multiforme) | iris |
| lesion shape: snakelike appearance | gyrate |
| lesion pattern: single lesion--demarcated lesions that reamin separate (insect bite) | singular/discrete |
| lesion pattern: lesions that bunch together in little groups (herpes simplex, impetigo) | grouped/clustered |
| lesion pattern: annular lesion that come into contact with one another as they spread (tinea corporis) | polycyclic |
| lesion pattern: lesions that merge and run together over large areas (pityriasis rosea) | confluent |
| lesion pattern: lesions that form a line (poison ivy, contact dermatitis) | linear |
| lesion pattern: lesions following a nerve (herpes zoster) | zosteriform |
| lesion pattern: lesions that are scatteren all over the body (herpes varicella) | generalized |
| a flat, circumscribed area that is a change in the color of skin; less than 1 cm in diameter...freckles, flat moles, petechiae, measles, scarlet fever | macule |
| an elevated, firm, circumscribed area less than 1 cm in diameter...wart, elevated moles, lichen planus, cherry angioma, skin tag | papule |
| a flat, nonpalpable irregular-shaped macule more than 1 cm in diameter...vitiligo, port-wine stains, mongolian spots, cafe-au-lait spots | patch |
| elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter...psoriasis, seborrheic and actinic keratoses, eczema | plaque |
| elevated irregular-shaped area of cutaneous edema; solid, transient; variable diameter...insect bites, urticaria, allegic reaction, lupus erythematosus | wheal |
| elevated, firm, circumscribes lesion; deeper in dermis than a papule; 1 to 2 cm in diameter...dermatofibroma erythema nodosum, lipomas, melanoma, hemangioma, neurofibroma | nodule |
| elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter...neoplasms, lipoma, hemangioma | tumor |
| elevated, circumscribed, superficial, not into dermis; filled with serous fliud; less than 1 cm in diameter...varicella, herpes zoster, impetigo, acute eczema | vesicle |
| vesicle greater than 1 cm in diameter...blister, pemphigus vulgaris, lupus erythematosus, impetigo, drug reaction | bulla |
| elevated, superficial lesion; similar to a vesicle but filled with purulent fluid...impetigo, acne, folliculitis, herpes simplex | pustule |
| elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material...sebaceous cyst, cystic acne | cyst |
| scaring caused by needle-track marks is generally indicatie of _____ | intravenous drug use |
| what are the 8 most important things to remember when describing a lesion? | location, size, color, shape, borders, elevated (flat, raised, sunken), characteristics (hard, soft, fluid filled, etc), pattern |
| headed-up keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size...flaking of skin with seborrheic dermatitis following scarlet fever, or flaking of skin following a drug reation; dry skin, pityriasis rosea, eczema, xerosi | scale |
| rough, thickened epidermis secondary to persisten rubbing, itching, or skin irritation; oftern involves flexor surface of extremity...chronic dermatitis | lichenification |
| irregular-shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound...from surgery | keloid |
| thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis...healed wound or surgical incision | scar |
| loss of the epidermis; linear hollowed-out crusted area...abrasion or scratch, scabies | excoriation |
| linear crack or break from the epidermis to the dermis; may be moist or dry...athlete's foot, cracks at the corner of the mouth, chapped hands, eczema, intertrigo labialis | fissure |
| dried drainage or blood; slightly elevates; variable size; colors variable--red, black, tan, or mixed....scab, eczema | crust |
| loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla....varicella, variola after rupture, candidiasis, herpes simplex | erosion |
| loss of epidermis and dermis; concave; varies in size....pressure ulcer, stasis ulcers, syphilis chancre | ulcer |
| thinning of the skin surface and loss of skin markings; skin appears translucent and paperlike....aged skin, striae, discoid lupus erythematosus | atrophy |
| a fine, irregular red line caused by permanent dilation of a group of superficial blood vessels | telangiectasia |
| a small, slightly raised, bright red area that typically appears on the face, neck, and trunk of the body. these increase in size and number with advanced age | cherry angioma |
| is a mass of extravasated blood confined to a space caused by a break in a blood vessel | hematoma |
| tiny, flat, reddish purple, nonblanchable spots in the skin less than .5 cm in diameter; appears as tiny red spots pinpoint to pinhead in size...cause: tiny hemorrhages within the dermal or submucosa due to intravascular defects and infection | petechiae |
| flat, reddish purple, nonblanchable discoloration in the skin greater than .5 cm in diameter...causes: infection or bleeding disorder resulting in hemorrhage of blood into the skin...senile, actinic purpura, progressive pigmented purpura, thrombocytopenic | purpura |
| a reddish purple, nonblanchable spot of variable size...cause: trauma to the blood vessel resulting in bleeding under the tissue | ecchymosis (bruise) |
| benign tumor consisting of a mass of small blood vessels; can vary in size from very small to large...cherry anginoma, hemangioma, cavernous hemangioma, strawberry hemangioma | angioma |
| a tyoe of angioma that involves the capillaries within the skin producting an irregular macular patch that can vary from light red to dark red, to purple in color...cause: congenital vascular malformation of capillaries...port win stain, stork bite | capillary hemangioma (nevus flammeus) |
| permanent dilation of preexisting small blood vessels (capillaries, arteriloes, or venules) resulting in superficial, fine, irregular red line within the skin....causes: rosacea, collagen vascular disease; actinic damage; increased estrogen levels | telangiectasia |
| a type of telangiectasia characterized by a small central red area with radiating spider-like legs; this lesion blanches with pressure....causes: may occur in absences of disease, with preg, in liver diseae, or with Vit B def | vascular spider (spider angioma) |
| a type of telangiectasia characterized by a nonpalpable bluish star-shaped lesion that may be liner or irregular shaped...cause: > pressure in the superficial veins | venous star |
| hair loss | alopecia |
| elevated ___ levels may be a reason for male's hairloss | androgen |
| hair loss on the legs may indicate ___ | poor peripheral perfusion |
| thinning of the eyebrows may indicate ___ | hypothyroidism |
| is hair growth in a male distribution pattern with an > of hair on the face, body, and pubic area | hirsutism |
| normal nail base is ___ degrees | 160 |
| is present when the angle of the nail base exceeds 180 degrees...may be caused by proliferation of the connective tissue between the nail matrix and distal phalanx...associated with respiratory or cardovascular problems, but may also be associated with ci | clubbing |
| thinning and brittleness of the nail may be secondary to ____ or ____ | poor peripheral circulation or poor nutrition |
| hypertrophy of the nail is usually secondary to repeated ___, ____, or ____ | trauma, fungal infection, or < vascular circulation |
| spoon nail | koilonychia...may be a sign of anemia |
| ___ of the nail is common;y associated with psoriasis | pitting |
| is a finding manifested by white spots observed on the nail plate...minor trauma or manipulation of the cuticle | leukonychia |
| manifest as a groove or transverse depression running across the nail that occurs as a result of a stressor that temporary impairs mail formation | beau's lines |
| white, waxy coating, _____ is a misture of sebum and cornified epidermis and covers the newborn's body | vernix caseosa |
| a newborn's body may be covered with fine silky hair called ___ | lanugo |
| ___ should be avoided as baby powder b/c it may foster the growth of monilia | cornstarch |
| an irregular shaped, darkened flat area over the sacral area and buttock...disappear after 1 or 2 years of age....common in AA, Asian, hispanic, native american | mongolian spots |
| a large round oval patach of light brown pigmentation that is generally present at birth | cafe-au-lait spots |
| two pigmentation variation birthmarks | mongolian spots and cafe-au-lait |
| small red or pink spots that often seen on the back of the neck...disappear by age 5 | stork bite |
| large flat bluish-purple capillary areas...most freq on face | port-wine stains |
| slightly raised, reddened areas with a sharp demarcation line | strawberry hemanginoma |
| a reddish blue round mass of blood vesssels...freq reassessment should be conducted | cavernous hemanginoma |
| 4 vascular birthmarks | stork bite, port wine stains, strawberry hemoanignoma, cavernous hemangioma |
| small, whitish papules that may be found on the cheeks, nose, chin, forehead of newborns...baby acne | milia |
| a common rash aoung newborns that is self limiting consisting of erythematous macules, papules, and pustules | erythema toxicum |
| 3 skin lesions of newborns/ infants | milia, erythema toxicum, diaper rash |
| hair on an infants lumbosacral area may suggest ___ | spina bifida or sinus tract |
| decreased ____ production leads to gray hair | melanin |
| irregular shaped, flat, deeply pigmented macules that may appear on body surface areas having repeated exposure to the sun | liver spots...solar lentigo |
| clients with situational variations are at risk for ____ | pressure ulcers and other skin problems |
| is an observable pressure-related alteration of intact skin whose idicators, as compared to an adjacent or oposite area of the body, may include changes in one or more of the following: skin temp, tissue consistenc, sensation...appears red | stage I pressure ulcer |
| partial-thickness skin loss involving epidermis, dermis, or both. the ulcer is superficial and apears clinically as an abrasion, blister, or shallow crater | stage II pressure ulcer |
| full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to , but not thru, underlying fascia. the ulcer manifests clinically as a deep crater with or without undermining of adjacent tissue | stage III pressure ulcer |
| fullpthickness skin loss with extensie destuction, tissue necrosis, or dmage to muscle, bone, or supporting structures (tendon, joint) | stage IV pressure ulcer |
| undermining and sinus tract may also be associated tieh stage ___ pressure ulcer | IV |
| is a lesion that develops secondary to chronic pressure from a shoe over a bony prominence | hyperkeratosis...clavus (corn) |
| is used to describe a variety of superficial inflammatory conditions of the skin that can be acute or chronic | dermatitis |
| is a chronic superficial inflammation of the skin with an unknown cause...common with fever and asthma----red, weeping, crusted lesions appear on face, scalp. extremeites, and diaper area | atopic dermatitis |
| is an inflammatory reaction of the skin in response to an irritant or allergen---localized edema, wheals, scales, or vesicles that may weep, ooze, and crust | contact dermatitis |
| is a chronic inflammation of the skin of unknown cause affecting individuals throughout their entire life, often with periods of remission and exacerbation..infants this is cradle cap---scaly, white or yellowish plaques on scalp, eyebrows, eyelids, nasola | seborrheic dermatitis |
| is an inflammation of the skin on teh lower legs most commonly seen in the older adult---areas of erythema and pruritis followed by scaling, petechiae, and brown pigmentation | stasis dermatitis |
| slivery scales on the surface of skin and lesions freq on the elbows, knees, buttocks, lower back, and scalp | psoriasis |
| caused by a number of dermophte fungal infections involving the skin, hair, and nails that affect childrenand adults | tinea infections |
| ring worm...involves generalized skin areas and appear circular and have clear center | tinea corporis |
| involves the scalp, causing scaling and pruitis with balding areas due to hair that breaks easy | tinea capitis |
| is a chronic infection involving the foot, athlete's foot | tinea pedis |
| funagl infection commonly on the GI tract, vaagina, skin, and mucous membranes | candidiasis |
| is an acute streptococcal or staphlococcal infection of the skin and subcutanous tissue....skin i sred and warm and tender | cellulitis |
| most common skin cancer | basal cell carcinoma |
| second most common skin cancer and an invasive form | squamous cell carcinoma |
| is the most serious form of skin cancer | melanoma |
| malignant neoplasm that affects those with AIDS and drug-induced immunosupression | kaposi's sacroma |
| pediculosis | lice |
| a chronic inflammatory disease of the hair follicles resulting in hair loss on the scalp | alopecia areata |
| a funal infection of hte nail plate caused by tinea unuium....plate turns yellow or white as hyperkeratotic debris accumulates | onychomycosis |
| involves an acute or chronic infection of the cuticle | paronychia |
| pus infection from an ingrown toenail | paronychia |
Created by:
TayBay15
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