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NUR 3066 Health Assessment > CH 13 Skin, Hair, and Nails > Flashcards

CH 13 Skin, Hair, and Nails Flashcards

1
Q

3 layers of skin

A

Epidermis
Dermis
Subcutaneous Layer (hypodermis)

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2
Q

Epidermis (structure/specifics)

A
  • outermost layer of skin
  • avascular
  • layer most commonly shed
  • Basal Cell Layer (innermost): new skin cell formation
  • Horny Cell Layer (outermost): flattened above layer of dead keratinized cells
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3
Q

3 Sources for Skin Color

A 
Melanin (brown)
Carotene (orange)
Vascular Bed (red-purple)
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4
Q

Dermis (structure/specifics)

A
  • inner supportive layer

- nerves, sensory receptors, blood vessels, and lymphatics

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5
Q

Subcutaneous Layer (structure/specifics)

A
  • layer of fat cells (stores for energy)

- provides insulation and protection for organs

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6
Q

Appendages (where? what?)

A
  • Hair (embedded in dermis)
    • vellus hair: soft/fine (arm/leg hair)
    • terminal hair: darker/thicker (scalp/eyebrows)
      (axialle and pubic area after puberty)
  • Sebaceous Glands (embedded in dermis)
    • produce sebum to lubricate skin and hair
  • Sweat Glands (embedded in dermis)
    • eccrine: open directly to skin surface
    • apocrine: open into hair follicles
  • Nails
    • color indicates oxygenation status
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7
Q

Skin Functions

A
  • protection/healing
  • adaptation (temp regulation/prevention of fluid loss)
  • production of vitamin D
  • others: excretion of waste, sensory perception, and storage of fat
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8
Q

Developmental Consideration and Changes: Infants

A
  • lanugo: fine hair (developed at 3 months of gestation)
  • lanugo replaced with vellus (first few months after birth)
  • many skin functions not fully developed
    • more permeable (greater risk of fluid loss)
    • insufficient subq layer (poor temp regulation)
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9
Q

Developmental Consideration and Changes: Children

A
  • epidermis thickens and hair growth accelerates
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10
Q

Developmental Consideration and Changes: Pregnancy

A
  • increased metabolism, secretion of sweat & sebaceous glands, and fatty deposits
  • skin changes:
    • striae: stretch marks
    • linea nigra: brownish/black line down midline
    • cholasma: hyperpigmentation of the face
    • vascular spiders (legs and back)
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11
Q

Developmental Consideration and Changes: The Aging Adult

A
  • skin atrophy, decreased elasticity
  • epidermis and dermis thin/flatten (wrinkling)
  • loss of collagen, subq fat, and muscle tone (risk for skin tearing)
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12
Q

Skin Assessment: Inspecting the Skin

why do assessment?

A
  • skin assessment helps collect information of nutritional status, circulation, and systemic disease
  • skin folds = perfect condition for moisture, irritation, and infection
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13
Q

Normal Findings of Skin

A
  • general pigmentation (even skin tone)

- benign pigmented areas

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14
Q

Assessment for Abnormal Findings

A 
ABCDEF Assessment
A (asymmetry)
B (border irregularity)
C (color variation)
D (diameter >6mm)
E (elevation/evolution)
F (funny looking)
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15
Q

Widespread Color Changes

A

Pallor (white)
- vasoconstriction/edema

Erythema (red)
- dilated superficial capillaries

Cyanosis (blue)
- decrease in perfusion/high level of de-oxygenated
blood

Jaundice (yellow)
- increased bilirubin in blood

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16
Q

Temperature (normal/abnormal)

A

Normal - warm and equal bilaterally

Abnormal

  • Hypothermia (low temp)
    - generalized (shock/cardiac arrest)
    - localized (immobilized extremity)
  • Hyperthermia (high temp)
    - generalized (increased metabolic rate -
    fever/exercise)
    - localized (trauma/infection/sunburn)
17
Q

Moisture (normal/abnormal)

A

Normal - normal perspiration

Abnormal

- Diaphoresis (profuse perspiration)
- Dehydration (dry mucosa are signs)
18
Q

Edema (what is it? How to assess?)

A
  • fluid accumulation in interstitial space
  • imprint thumb for 3-4 sec
    (if imprint left behind = pitting edema)
19
Q

Mobility & Turgor

A
  • assess elasticity in skin
  • mobility: ease of skin to rise
  • turgor: measures how skin returns to place
    - abnormal = tenting (skin stays up for few sec)
20
Q

Skin Assessment: Lesions (what is it? important findings? primary vs secondary)

A
  • lesions: traumatic/pathologic changes in normal structures
  • palpate and note surround temperature
  • important findings
    • color, elevation, patter/shape, size, location, exudate
  • primary: develops on previously normal skin
  • secondary: when primary lesion changes over time because of scratching or infection
21
Q

Primary Lesions (7 types)

A
  1. Macule and Patch (flat, nonpalpable, circumscribed border)
    • EX. freckles, vitiligo, measles
    • macule <1cm
    • patch >1cm
  2. Papule and Plaque (elevated, solid, palpable)
    • EX. warts, psoriasis, actinic keratosis
    • papule <0.5cm
    • plaque >0.5cm
  3. Nodule and Tumor (more palpable mass/deeper in dermis than papule)
    • EX. lipoma, carcinoma
    • nodule 0.5-2cm
    • tumor >2cm
  4. Vesicle and Bulla (elevated, fluid-filled, round/oval, superficial, translucent)
    • EX. herpes, chickenpox, blister
    • vesicle <0.5cm
    • bulla >0.5cm
  5. Wheal (elevated, irregular shape, reddish/edematous)
    • EX. insect bite, allergic reaction, hives
  6. Pustule (purulent-filled vesicle)
    • EX. acne
  7. Cyst (elevated, walled off-encapsulated
    • containing fluid or semi-solid material
22
Q

Secondary Lesions (8 types)

A
  1. Crust (dry blood/pus from burst vesicle/pustule)
    • Ex. scabs
  2. Scales (shedding flakes of dry skin)
    • EX. dandruff, psoriasis, eczema
  3. Lichenification (rough and thickened)
    • secondary to scratching
    • EX. chronic dermatitis
  4. Erosion (wearing away of superficial epidermis w/o bleeding)
    • No scar
    • EX. ruptured vesicle
  5. Ulcer (deeper depression into dermis or subq, may bleed)
    • will scar
    • EX. pressure injury
  6. Fissure (linear break in skin surface)
    • EX. cracks in corner of mouth
  7. Scar (fibrotic change where collagen replaces normal tissue)
  8. Keloid (elevated and irregular/overproduction of scar tissue)
    • usually benign
    • common from surgery, acne, piercing, infections
23
Q

Common Patterns/Distribution of Lesions

A

Annular (circular)
Ex. ringworm (tinea corpori)

Confluent (lesions that run together)
Ex. Urticaria (hives)

Discrete (individual lesions/separate
Ex. warts, skin tags

Grouped (appear in clusters)
Ex. poison ivy

Zosterform (linear along unilateral nerve route)
Ex. herpes zoster (shingles)

24
Q

Physical Variation in Skin Color (Vessel Bleeding)

A

Petechiae (bleeding from superficial capillaries)

  • nonblanchable
  • tiny hemorrhages (1-3mm)

Purpura (extensive patch of petechiae)

  • red, nonblanchable
  • > 3mm

Contusion (bruise)

Ecchymosis (severe bruising)

25
Q

Pressure Injuries (found where? common sites? risk factors? stages? other?)

A

Usually found over bony prominence

Common sites: heel, ischium, sacrum, vertebrae, ankle, rib, shoulder

Risk factors: impaired mobility, decreased sensory perception, trapped moisture, thin skin with aging

Stages:

  • Stage 1
    - non-blanchable erythema
    - skin still intact
  • Stage 2
    - paritial- thickness skin loss
    - skin not intact/exposed dermis
  • Stage 3
    - full-thickness skin loss (rolled edges)
    - into subq tissue
  • Stage 4
    - full-thickness skin/tissue loss
    - extends to bone/tendon/muscle

Other
- Deep Tissue Pressure Injury (not open but as serious as stage 3/4)

26
Q

Malignant Skin Lesions (general blanket statement; 3 types)

A

Strong link between skin cancer and UV light radiation (sunlight and tanning beds)

Basal Cell Carcinoma
- most common of skin cancer
- donut shape (indentation in the middle) (small pink,
red papule)

Squamous Cell Carinoma
   - arise from actinic keratosis
   - erythematous scaly patch
   - less common than basal cell, but grows more 
      rapidly

Malignant Melanoma

  • may arise from pre-existing mole
  • most dangerous of the three
  • usually brown and irregular with notched borders
  • men: common on trunk and back
  • women: common on legs and feet

NUR 3066 Health Assessment (20 decks)

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