Nursing 3180 Health Assessment Exam 2

Exam 2 Health Assessment Chapter 12- Skin, Hair, Nails Skin changes that occur in aging  Skin loses elasticity, folds and sags. By 70-80 it looks parchment, thin, lax, dry, and wrinkled. Outer layer of the epidermis thins and flattens. A loss of elastin, collagen, and subcutaneous fat and reduction in muscle tone occurs. The loss of collagen increases the risk for shearing, tearing injuries. Decrease of sweat, sebaceous glands, response of sweat glands leaving dry skin. Vascularity of the skin diminishes while the vascular fragility increases; a minor trauma may produce dark red discolored areas or senile purpura. Major reasons skin assessment is important (What does it tell us)  Check for any abnormal findings that could indicate a disease. Know the physical presentation of pressure ulcers (what would each stage be described as)  Stage 1- intact skin appears red but broken. Localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure) dark skin appears darker but does not blanch.  Stage 2- Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with red-pink wound bed.  Stage 3- Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle bone or tendon.  Stage 4- Full- thickness pressure ulcer involves all skin layers and extends into supporting tissue. Exposes muscle, tendon, or bone. May show slough or eschar (necrosis) Xerosis- Abnormally dry skin. Dry skin is common, especially in the elderly. It is usually a minor and temporary problem, but may cause discomfort. Your skin needs moisture to stay smooth. Pruritus- Severe itching of the skin, as a symptom of various ailments. Alopecia- Sudden hair loss that starts with one or more circular bald patches that may overl Seborrhea- A skin condition that causes scaly patches and red skin, mainly on the scalp. Normal angle of base of nail What is clubbing- is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs. Chapter 13- Head, Face & Neck Vertebra Prominens- The seventh cervical vertebra characterized by a prominent spinous process which can be felt at the base of the neck. The Salivary glands that are able to be examined are  Parotid and Submandibular The lymph nodes on the head and neck are located