Where is the best place to observe for the presence of petechiae in dark-skinned individuals

Q27:
Inhaltsverzeichnis Show
When assessing a preschooler's chest,what should the nurse expect? A) Respiratory movements to be chiefly thoracic B) Anteroposterior diameter to be equal to the transverse diameter C) Retraction of the muscles between the ribs on respiratory movement D) Movement of the chest wall to be symmetric bilaterally and coordinated with breathing
Q28:
Which is the most frequently used test for measuring visual acuity? A) Snellen letter chart B) Ishihara vision test C) Allen picture card test D) Denver eye screening test
Q29:
During a routine health assessment,the nurse notes that an 8-month-old infant has a significant head lag.Which is the most appropriate action? A) Recheck head control at next visit. B) Teach the parents appropriate exercises. C) Schedule the child for further evaluation. D) Refer the child for further evaluation if the anterior fontanel is still open.
Q30:
The nurse needs to take the blood pressure of a small child.Of the cuffs available,one is too large and one is too small.The best nursing action is which? A) Use the small cuff. B) Use the large cuff. C) Use either cuff using the palpation method. D) Wait to take the blood pressure until a proper cuff can be located.
Q31:
Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? A) Vesicular B) Bronchial C) Adventitious D) Bronchovesicular
Q33:
The nurse is assessing a child's capillary refill time.This can be accomplished by doing what? A) Inspect the chest. B) Auscultate the heart. C) Palpate the apical pulse. D) Palpate the nail bed with pressure to produce a slight blanching.
Q34:
The nurse is caring for a non-English-speaking child and family.Which should the nurse consider when using an interpreter? A) Pose several questions at a time. B) Use medical jargon when possible. C) Communicate directly with family members when asking questions. D) Carry on some communication in English with the interpreter about the family's needs.
Q35:
Superficial palpation of the abdomen is often perceived by the child as tickling.Which measure by the nurse is most likely to minimize this sensation and promote relaxation? A) Palpate another area simultaneously. B) Ask the child not to laugh or move if it tickles. C) Begin with deeper palpation and gradually progress to superficial palpation. D) Have the child "help" with palpation by placing his or her hand over the palpating hand.
Q36:
What is the appropriate placement of a tongue blade for assessment of the mouth and throat? A) On the lower jaw B) Side of the tongue C) Against the soft palate D) Center back area of the tongue
Q37:
Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? A) S1 and S2 B) S3 and S4 C) Murmur D) Physiologic splitting

Your 75-year-old patient is short of breath. Knowing his natural skin tone is dark, you’re unsure how to assess for central cyanosis.

An adolescent patient has a serious soft-tissue injury of the leg, but you can’t see bruising because her skin is darkly tanned.

After a sexual assault, a dark-skinned patient arrives at the emergency department with a suspected abrasion of the labia minor. But even when you apply contrast medium, the injury is hard to detect because of the surrounding skin color.

The skin is the body’s largest organ. Skin color can reflect a patient’s overall health and is an important part of assessing skin breakdown and wound healing. For instance:

pallor may indicate anemia
cyanosis may signal hypoxemia
the degree and extent of skin redness is important in burn care
understanding skin-color changes is crucial for detecting and staging pressure ulcers.

But the exact nature of such color changes as pallor, cyanosis, and redness varies with the patient’s natural skin color—and this can pose a challenge in providing clinically competent and culturally sensitive care. Long a source of discrimination, skin color is a socially sensitive issue. Identifying and evaluating skin color raises questions about stereotyping and the social benefits of being “color-blind.”

Most skin-care guidelines apply mainly to patients with light skin. Yet the Hispanic and Asian populations of the United States are expected to triple over the next half-century. By 2050, people of Hispanic, African, Asian, and Caribbean ancestry likely will represent more than half the total U.S. population. Obviously, healthcare professionals will be caring for an increasingly diverse population of many ethnic backgrounds and skin colors. This article explores the concept of skin-color awareness, discusses the role of skin color in nursing assessment, and explains why healthcare providers should practice color awareness, not blindness.

Constitutive vs. facultative skin color

Constitutive skin color is the natural, genetically determined color of the epidermis, uninfluenced by ultraviolet (UV) light or hormone exposure. Typically, it’s seen in areas of little or no sun exposure, such as the underside of the upper arm.

In contrast, facultative skin color results from exposure to UV light and other environmental factors. Tanning, for instance, changes the composition of melanin in the skin and increases the amount and size of melanin produced by melanocytes. Thus, facultative skin is darker than constitutive skin. (See the box below.)

How skin gets its color

Melanocytes are cells in the epidermis (the skin’s outer layer) that are genetically programmed to produce a specific amount of melanin—the pigment that gives skin its specific color. Skin color is the result of reflected and absorbed light from unpigmented skin, mixed with colors of various constitutive pigments, such as melanins, hemoglobins, and carotenes. As light hits the skin’s surface, it is either reflected diffusely back, scattered, or absorbed by particles within the skin. The most superficial layer of the epidermis transmits most light through to the more basal layers of the epidermis, dermis, and hypodermis. These layers scatter some light while melanin in the epidermis absorbs light, producing an orange, brown, or black color.

In the dermis, some light is scattered and some is absorbed by collagen, yielding a yellowish color. In both the epidermis and dermis, carotene absorbs light, also creating a yellow hue. Hemoglobin in the superficial capillaries absorbs some light; oxygenated hemoglobin produces a reddish tint while reduced hemoglobin yields a bluish color. Finally, the subcutaneous fat layer in the hypodermis scatters back a large portion of light that has made it through all the layers.

Why color “blindness” can reduce health outcomes

Skin color may be a source of disparate health outcomes for many reasons, not just discrimination or poor access to care. Disparity can occur if well-intentioned healthcare professionals are color “blind”—disregarding a patient’s skin color because they believe doing this will help them provide the same level of care to all patients regardless of skin color. But this approach limits the relevance of skin color to health and limits nurses’ ability to provide individualized care.

For instance, as a nurse you’ve been trained to assess skin breakdown by testing the skin’s blanch response to light finger pressure. When evaluating for a stage I pressure ulcer, you apply light pressure to the skin; this temporarily squeezes blood out of the underlying area, reducing local blood volume and causing an area of blanching, or whitening. If the skin appears red, blue, or purplish and doesn’t blanch, you might classify the area as a stage I pressure ulcer. But in dark-skinned patients, the blanching test has limited value. The greater amounts of melanin in dark skin may mask the blanch response, making the color change invisible despite the local change in blood volume.

Forensic implications

What’s more, researchers studying forensic sexual assault examinations found data suggesting black women had a lower prevalence of genital injury after rape than white women. They suggested that the difference in reported injury prevalence wasn’t related to race or ethnicity but to either reduced visibility of injury in dark-skinned women (compared to light-skinned women) or actual differences in skin properties, depending on skin color. They also found dark-skinned women had fewer injuries than light-skinned women after consensual sexual intercourse. Their research showed that skin color more fully explained the differences in the numbers of genital injuries than race or ethnicity in both groups of women—those who’d been raped and those who’d had consensual intercourse. In other words, the prevalence of genital injuries in dark-skinned women has likely been underreported because of difficulty seeing the injuries.

These findings are particularly important given the role of forensic evidence in the criminal justice system. Women whose injuries are documented during the forensic examination have better judicial outcomes at every step of criminal justice proceedings than women without documented injuries. Those with documented injuries are more likely to report rape to the police, more likely to file charges, more likely to have their cases prosecuted, and more likely to have the accused persons convicted.

Cultivating color awareness

Unlike color “blindness,” color awareness acknowledges that skin color is relevant to health and shouldn’t be ignored. What’s more, it acknowledges that people across the skin-color continuum may not want to be treated as raceless, colorless, or without ethnicity, since much of a person’s identity stems from being a specific color. By applying color awareness to health assessment, healthcare professionals can more appropriately manage skin conditions among patients of all skin colors and help reduce disparities in healthcare delivery.

Skin color assessment methods

The most common way to assess skin color is to use the Fitzpatrick scale, which was developed to classify skin type during a study of UV dosing in psoriasis treatment. (See the box below.) The latest version of this scale classifies skin into one of six types based on its reaction to sun exposure. However, this scale isn’t particularly helpful in nursing assessment because of its focus on the effects of sun exposure and because dark-skinned people fall into primarily one category.

Other assessment scales use different classification criteria. One scale classifies skin color as dark, darkish, or fair. A second scale uses four categories—fair, fair/medium, medium, and dark. A third uses a skin-tone chart consisting of eight categories of color ranging from 1 (lightest) to 8 (darkest).

Skin color also can be assessed through digital image analysis or measured with such instruments as a spectrophotometer or colorimeter. These techniques generally are used in research, to collect forensic evidence, or during dermatologic procedures. For clinical skin-color assessment, visual inspection and asking patients about their normal skin color are the best methods.

Recommendations for assessing dark-skinned patients

When assessing a patient’s skin, use natural light or a halogen lamp rather than fluorescent light, which may alter the skin’s true color and give the illusion of a bluish tint.

Skin color is particularly important in detecting cyanosis and staging pressure ulcers. Cyanosis occurs when a person has 5 g/dL of unoxygenated hemoglobin in the arterial blood. Central cyanosis (cyanosis of the lips, mucous membranes, and tongue) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels. In light-skinned patients, cyanosis presents as a dark bluish tint to the skin and mucous membranes (which reflects the bluish tint of unoxygenated hemoglobin). But in dark-skinned patients, cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish. In patients with yellowish skin, cyanosis may cause a grayish-greenish skin tone.

Checking for pressure ulcers

When checking for pressure ulcers in dark-skinned patients, remember that dark skin rarely shows the blanch response. Instead, after applying light pressure, look for an area that’s darker than the surrounding skin or that’s taut, shiny, or indurated (hardened). If you suspect a skin area is becoming damaged, use the light from a camera flash system to enhance your visualization of dark skin; with the patient’s permission, take a series of digital images each day to document changes in wound color, size, and depth. Check for localized changes in skin texture and temperature. Early signs of skin damage include induration, bogginess (less-than-normal stiffness), and increased warmth at the injury site compared to nearby areas. Over time, as tissues become more damaged, the area becomes cooler to the touch.

Erythema also may be hard to detect in dark-skinned patients. In a light-skinned patient, irritation may cause redness. But in a dark-skinned person, it may cause hyperpigmentation (increased pigmentation) or hypopigmentation (reduced pigmentation), with no redness visible. Sometimes, dark skin takes on a dark bluish-purple tint at the site of early pressure-ulcer development. So when caring for a dark-skinned patient at risk for pressure ulcers, keep in mind that assessing by touch is as important as visual inspection. (See the box below for more assessment tips).

To provide high-quality care for dark-skinned patients, healthcare professionals shouldn’t use skin assessment standards based on light skin color. We must increase the body of knowledge pertaining to appropriate methods for assessing skin colors along the entire continuum. Until all healthcare disciplines practice color awareness, we may be promoting healthcare disparities based on skin color. We can’t afford to be “color-blind.”

Selected references

Choe YB, Jang SJ, Jo SJ, Ahn KJ, Youn JI. The difference between the constitutive and facultative skin color does not reflect skin phototype in Asian skin. Skin Res Technol. 2006;12:68-72. doi:10.1111/j.0909-725X.2006.00167.x.

deRigal J, Mazis ID, Diridollou S, et al. The effect of age on skin color and color heterogeneity in four ethnic groups. Skin Res Technol. 2010;16:168-178. doi:10.1111/j.1600-0846.2009.00416.x.

Sachdeva, S. Fitzpatrick skin typing: applications in dermatology. Indian J Dermalot Venereol Leprol. 2009;75:93-96. doi:10.4103/0378-6323.45238.

Sommers MS, Zink T, Baker RB, et al. The effects of age and ethnicity on physical injury from rape. JOGNN. 2006;35(2):199-207. doi:10.1111/J.1552-6909.2006.00026.x.

Sommers MS, Zink TM, Fargo JD, et al. Forensic sexual assault examination and genital injury: is skin color a source of health disparity? Am J Emerg Med. 2008;26:857-866. doi:10.1016/j.ajem.2007.11.025.

Yamaguchi Y, Brenner M, Hearing V. The regulation of skin pigmentation. J Biol Chem. 2007;282:27557-27561. doi:10.1074/jbc.R700026200.

Marilyn S. Sommers is the Lillian Brunner Professor of Medical-Surgical Nursing at the University of Pennsylvania School of Nursing in Philadelphia.

Where do you check for petechiae on dark skin?

Petechiae are tiny purple, red, or brown spots on the skin. They usually appear on your arms, legs, stomach, and buttocks. You might also find them inside your mouth or on your eyelids. These pinpoint spots can be a sign of many different conditions — some minor, others serious.

Where is the best place to assess for petechiae?

The skin should undergo thorough examination from head to toe, and the pattern of rash requires clear documentation. Demarcating areas of petechiae with a skin marker can help monitor the progression of the rash in clinical practice.

Where is the most reliable location to assess for petechiae in a person with darkly pigmented skin?

Petechiae may be very difficult to recognize in the skin of darkly pigmented people. The conjunctiva may show petechiae (Figure 2). At autopsy, a common place to find petechiae is the undersurface of the scalp (Figure 3).

When assessing a dark

Here are conditions and techniques to use in the assessment of darkly pigmented skin: Cyanosis—Inspect the conjunctivae, palms, soles, oral mucosa and tongue. Pallor—Inspect the sclera, conjunctivae, oral mucosa, tongue, lips, nail beds, palms and soles.