Ch 19, 26(MedS)

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khonka
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108635
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Ch 19, 26(MedS)
Updated:
2011-10-14 02:20:26
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N113
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Assessment of hair, nails, neck, head in injections.
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  1. Anatomy and physiology of the skin
    • Subcutaneous fat - fat cells as an energy reserve also act as heat insulators, absorb shock and protect against injury
    • Dermis - layer above the fat layer all connective tissue that contains no cells - collagen and elastic fibers to give flexibility and strength. Fibroblasts - form scars, give turgor of the skin. Exchange of oxgen and heat, sensations of touch, pressure, temp. pain, itch.
    • Epidermis - outer layer. protective barrier between the body and environemnt. Resceives nutrients by defusion. Keratinocytes constantly devide to form new layers of skin, waterproof. Where vit D is activated. Melanocites give color to the skin. Protects the skin form UV.
  2. A&P of the Hair
    Hair folicals located in the dermal layer of the skinbut are actually extension ofthe epidermal lyaer. with in each folicle is a round column of keratin forms the hair shaft. Hair color - by rate of melanin production
  3. A & P of the nails
    also the extension of epidermis keratin produced. Pink color - reach blood supply
  4. Pallor
    • in light skinned clients; estreme paleness; skin appears white; loss of pink or yellow tones. In dark skined clients: a loss of red tones.
    • Associated with poor circulations or anemia. Asses oral mucouse membranes, nail beds, palms and soles of feet.
  5. Cyanosis
    • a blue gray coloration of the skin often described as ashen.
    • Central cyanosis: lips, tonegue, mucouse membranse, and facial features and associated with hypoxia.
  6. Erythema
    rennened area associated with rashes, skin infections, prolonged pressure on the skin.
  7. Ecchymosis
    Bruised(blue-green-yellow) area. Interal bleeding, side effect of med, bleeding disorder. Does not blench
  8. Petechiae
    • Tiny, pinpoint red or reddish-purple spots. From extravasation: leakage from vesseles from blood into the skin. Same as purpura and ecchymoses
    • Indicate increased capillary fragility
  9. Mottling
    Bluish marbling. Occures in lights0skinned clients, especially when cold.
  10. Skin Turgor
    • refers to the elasticity of the skin, which tells about hydration data.Pinch skin over a clavicle or the back of the hand.
    • Tenting: skin that staid piniched for a few seconds
  11. Edema
    • escessive ammount of fluid in the tissues. Common in gocnegstive heart failure, kidney disease, peripheral vascular disease, or low albumin levels.
    • Assessing Edema: Trace- minimal depression is noted with pressure.
    • +1 --2mm depression, rapid return
    • +2 4mm disappears in about 10-15 sec
    • +3 6mm lasts 1-2 min The area appers slwallen
    • +4 8mm for 2-3 min, area is grossly edematous
    • Med-serg
    • Localized: inflamatory response, trauma
    • Pitting: FLuid and electrolite imbalance. Ambuatory - drusum of foot and medial ankle. Congestive heart failure and ranal disease. Venouse and cardiac insuficiency - bedridden: buttocs, sacrum, and lower back in hepatic cirrhosis and venous trhombosis or stasis
    • Nonpitting: Endocrine imbalance - generalized but more easily seen over tibia in hypothyroidism
  12. Lesions
    • variations in pigment or break in continuous tissue. ex. crusts that form from reptured pustules. Evaluae it for size, shape, pattern, color, distribution, texture(smooth, rough, scaly), surface relationsip(flat, raised, is it attached or mobile), exudate(drainage?odor), tenderness, pain or itching.
    • Assess for malignensy use ABCDE
    • A asymmetry
    • B Border irregularity
    • C Color variations
    • D diameter 0.5 cm and bigger
    • Terms to descibe Lesions in Med-Surg book on page 471 table 26-3
  13. moisture of the skin
    • Xerosis: excessive dryness
    • Diaphoresis: excessive moisture
  14. Arterial Insufficiency
    smooth, think, shiny skin with no heir
  15. Venouse insufficiency
    Thick, rough skin
  16. Integrity of the skin
    • thorough examinining areas with actula breaks or open areas.
    • describe breaks in skin integrity by their location, size, color and distribution and presenc eof darinage or any signs of infection.
    • Evaluate cleanliness of the skin; hair, nails, skin for soiling and offensive odor.
  17. Assessing the Hair
    • Inspection and palpation
    • Assess scal phair and bod hair
    • Inspet hair for color, quality, distribution,condition of scalp, and presence of lesions, and presence of lesions or pediculosis(bshivost')
    • Hirsutism: excess facial or trunk hair
    • Alopecia: hair loss
    • Palpate texture of the hair (fine, medium, coarse)
    • Palpate the scalp for mobility and tenderness (lessions, tenderness, scars)
    • amount ( sparse-redkii, thick)
    • dry and coarse - hypothyroidism
    • thin and silky - hyperthyroidism
  18. Assessing the Nail
    • Color: pale or cyanotic nail beds - circulatory or respiratory disorders result in anemia or hypoxiya
    • Capillary refill: good circulation to the extrimities in 2-3 seconds. Press end of the finger if nail poish is present
    • Texture: thickened -poor circulation. Yellowing - fungal - onychomycosis. Brittle nails - hyperthyroidism, malnutrition, calcium and irond deficiency. Soft, boggy - poor oxygenation.
    • Shape: clubbing -nail plate angle is 1800 or more becuase of hypoxia. Spoon shaped - iron deficiency
    • Acute paronychia: iflomation of the skin around the nail associated with torn cuticle or an ingrown toenail
    • Half and Half: distal band of reddis-pink covering 20-60% of nails - ranel disease, hypoalbuminemia
  19. Normal and Abnormal skin color for Dark Skin patients
    • CYANOSIS
    • Examine lipes and tongue for gray color
    • Examine nail beds, palms and soles for blue tinge
    • Examine conjuectiva for pallor
    • INFLAMMATION
    • Compare affected area with nonaffected area for increased warmth
    • examine the skin of the affected area to determine whether it is shiny or taut or pits with pressure
    • Compare the skin color of affected area with the same area on the opposite side of the body
    • Palpate the affected area and compare it with unaffected area to determine whether texture is different (afacted area may feel hard or "woody")
    • JAUNDICE
    • Check for yellow tinge to oral mucous membrances, espacially the hard palate
    • Examine the sclera mearest to the iris rather than the corners of the eye
    • BLEEDING
    • Compare the affected area with the same area on the unaffected body side for swelling or skin darkening
    • If the patient has thrombocytopenia, petechiae may be present on the oral mucosa or conjuctiva.
  20. Assessment of the Head
    • HEENT
    • Head
    • Eyes
    • Ears
    • Nose
    • Throat
    • Asymmetry may be the result of trauma, surgery, neuromuscular disorder, paralysis, congenital deformity
    • Check for:
    • Size: normacephalic, erect midline. proportional to the body size. Abnormal - acromegaly, asymmetry or skull
    • Irregular or uneven movement of the jaw; pain or popping with movement
  21. Assessing the neck
    Note symmetry, range of motion the the condition of the skin - neck is erect, midine, ans symmetrical with full ROM. No masses are present, skin is intact.Thyroid is not visible
  22. Assessment of the Face
    • Abnormal Findings
    • Bell's palsy
    • Down syndrome
    • Graves disease
    • Myxedema
    • Cacheia
    • Cushing's syndrome
  23. Facial structures that should appear symmetric
    • nosalabial fold (between nose and corner of the mouth)
    • palpebral fissure (eye oppening)
  24. Braden Scale
    • the lower the number the higher risk factor for pressure soars
    • if number between 13-18 and a major risk factors are present, than advance to he next level of risk.
  25. 6 components of Braden Scale
    • Sensory perception
    • Moisture
    • Activity
    • Mobility
    • Nutrition
    • Friction and shear
  26. 4 protocols by risk level from Braden's scale
    Veiw Braden Scale print out

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