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HEALTH ASSESSMENT
CHAPTER 13
Question | Answer |
---|---|
SKIN STRUCTURE | EPIDERMIS-OUTER LAYER-REPLACE Q4W DERMIS-INNER LAYER-COLLAGEN-BLOOD VESSEL-NERVES-KEY PART OF LYMPHATIC SYSTEM SUBCUANEOUS LYER-ADIPOE TISSUE-INSULATION-ENERGY-PREVENT AGAINT TRAUMA-INJURIES |
HAIR | HORMONES AFFECT HAIR I.E TESTOSTERONE SEBACEOUS GLAND-PRODUCE SEBUM EVERYWHERE-EXCEPT PALMS AND SOLES SWEAT GLAND ECCRINE-THIN SALINE BASED APPOCRINE-THICKER-STICKER-NIPPLE, GENITALIA |
NAIL | TELL PATIENT IS HAVING HYPOXIA |
FUNCTION | PROTECTION- BARRIER COMMUNICATION-BLUSHING WOUND REPAIR PRODUCE VITAMIN D |
DEVELOPMENT-INFANT | INFANT LANUGO(HAIR)-BACK AND SOULDER VERNIX CASEOSA-MADE OF EPITHELIAL CELL TO PROTECT FROM ANMIONIC FLUID-BASED O RACE-PIGMENT HASN'T STARTED DEVELOP |
CHILD | THICKENING OF EPIDERMIS-THOUGHER HAIR GROWTH, SWEAT AND SEBACEOUS GLAND PRODUCTON-ADIPOSE TISSUE |
ADOLESCENTS | APPEARANCE OF SECONDARY SEX CHARACTERISTICS COURSE HAIR |
PREGNANCY | CELL REPRODUCING IN QUICKER RATE{PRENATAL VITAMINS) HAIR, NAIL, SKIN GROWTH PERIPHERAL VASODILATION-RASH, SWELLING INCREASE SWEAT ND SEBUM SECRETION FAT DEPOSIT(HIP) SKIN CHANGE(HORMONAL) LINEANIGA |
AGING ADULT THINNING HAIR, GRAY-WHITE HAIR(LESS MELANIN) SLOW-GROWING , RIDGED NAILS-DECREASE CELLULAR REPRODUCTION-VIT-NUTRIENTS DEFICIENCY | EPIDERMIS FLATTEN-REDUCE COLLAGEN-SUNQ FAT=WRINKLES INSCREASE RISK TO SKIN TEAR DECREASE IN SWEAT AND SEBACEOUS FUNCTION-HEAT STROKE DECREASED VASCULARITY(SENILE PURPURA)-DAMAGE TO CONNECTIVE TISSUE=BRUISING-DECREASED ABILITY TO HEAL |
CULTURAL AND GENETICS | MELONOMA-HIGHEST IN WHITE POPULATION INCREASED SUN EXPOSURE- TANNING BEDS ATYPICAL MOLES-DIAMETER GREATER THAN 4/1INCH-ASYMMETRY.BORDER.COLOR.DIAMETER.EVOLUTION NATURAL BLONDES/READ HEADS INCREASED AGE |
OTHER SKIN TYPES | KELOIDS-HUGE SCAR- PSEUDOFOLLICULITIS-COMMON IN DARK-RAZOR BURN-UNGROWN HAIR-INFLAMED-FILLED W/ PUS-ITCHY MELASMA-FLUCTUATION OF HORMONE |
subjective data hirsutism-imbalance hormal nail? perform own self exam? cdertain soap | any tatoos and piercing hx of skin/abnormalities-how long /? tell me more about it change in moles(abcde) pigmentation? rash, lesions? location, onset, systemic? prutitis (itching)-what makes it better? different stage of bruising? bleeding |
infants and children | birthmarks-Changes in skin color3.Rashes or sores 4.Burns or bruises? 5.Contagious conditions? Habits-pull hair-bite nails sunburns- |
ADOLESCENTS | Acne?2.Pimples?3.Blackheads? pattern, skin care routine |
AGING ADULTS | Changes to skin 2.Delays in healing 3.Pain?4 RASH-SHINGLES .Falls Self-care-ARE YOU ABLE TO WASH YOUR OWN, HAVE SOAP |
OBJECTIVE DATA | Equipment:•Good light! •Centimeter ruler•Penlight•Gloves MAGNIFY CLASS PG 204 |
NORMAL-SKIN | Freckles (ephelides)•Moles (nevus) – Junctional → Compound•Birthmarks |
ABNORMLITIES | PALLOR-PERFUSION ISSUE-WHITE MUCOUSCMOUTH-HYPOVOLEMIA -HEMOGLOBIN ERYTHEMA-REDNESS-INCREASED BLOOD FLOW TO DILATE CAPILLARIES CYANOSIS-O2 JAUNDICE-BABY W/ BILIRUBIN, OR LIVER FAILURE COPD-HARSHON(PROLONGED DECREASED OXYGENATION) DECREASE PERFUSION |
Skin Inspection & Palpation NO TENTING ELASTIC SKIN TURGOR | Temperature: •Hypothermia-COLD TO TOUCH •Hyperthermia •MOISTURE:•Diaphoresis(SWEATING HYPOGLYCEMIA) •Dehydration •Texture-CALLUS, •Thickness•Scleroderma-CON.TISSUE HARDEN •Edema:•Pitting/non-pitting (CARDIO, RENAL)•Anasarca(WHOLE BODY) •Turgor |
Skin Inspection & Palpation | Vascularities: •Ecchymosis - bruising•Cherry angioma •Lesions: •Color•Elevation•Pattern/shape•Size•Location/distribution•Exudate(BODY NATURAL RESPONSE TO HEAL A WOUND-FLUID CLAMPING TOGETHER TO FORM SCABS-NCROSIS RED-INFLAMMATORY •TATOOS, NEEDLEMARK |
Hair Inspection & Palpation | •Color•Texture •Distribution• Hirsutism •Alopecia•Lesions •Seborrhea-DANDRUFF Infestations -ITCHING PEDICULE |
Nail Inspection & Palpation | Shape and contour •Clubbing-SECONDARY TO PROLONGED OXYGENATION ISSUES •Consistency-SMOOTH, RIGID-FUNGUS- •Color-BLUE-O2-COLD- •Capillary Refill-GOES BACK TO NORMAL COLOR IN 3 SECS, MORE THAN 4 SECS, PERFUSION ISSUES |
AGE SPECIFIC-INFANTS | Skin:•Skin color:•Mongolian spot•Café au lait spot •Skin color change:•Harlequin color change•Erythema toxicum•Cyanotic CONDITIONS-BLUE EXTREMETIES:•Acrocyanosis•Cutis marmorata-LOW HR-BLUE•Jaundice•Carotenemia(TOO MUCH CARROT) |
AGE SPECIFIC-INFANTS | Skin moisture:•Vernix caseosa •Skin texture:•Milia •Skin thickness:•Thin in newborns•Extremely thin in premies •Vascularity:•Nevus simplex •Hair:•Lanugo• Nails:•Bluish immediately after birth then pink |
Developmental – Age Specific | •Adolescents:•acne•Pregnant Women:•Striae•Linea nigra•Cholasma•Vascular spiders |
•Aging Adults: •Skin color:•Senile lentigines•Keratoses •Moisture:•Dryness, flaky•Texture:•Acrochordons (skin tags)•Sebaceous hyperplasia •Thickness: thin•Hair: thinning, gray or white •Nails: brittle•Mobility and Turgor: decreased, tenting | |
PRESSURE ULCER- | ADDRESS-TURN THEM EVERY 1-2 HOURS DOCUMENT HIGH RISK-MOBILITY-AGE-MALNOURISHMENT |
STAGES UNSTAGEABLE-WOUND BED IS COVERED WITH NECROSIS(SURGICALLY DEBRITATED | STAGE 1-BLANCHABLE-PRESS SKIN, BLOOD REFILL NON-BLANCHABLE-SKIN INTACK-REDNESS STAGE 2-OPEN OF EPIDERMIS-BLISTER-FLUID FILLED 3-LOSS OF DERMIS-MAY SEE SUBQ STAGE 4-LOST OF ALL LAYER EXPOSED BOONE -MUSCLE, TENDON STAGE 5- SIN MAYBE INTACK,PURPLE MA |