CH 13: Skin Hair Nails and Wounds Flashcards

1
Q

what is the largest organ?

A

skin

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2
Q

what does skin do?

A

first line defense
protects
supports
adapts

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3
Q

when do you conduct skin assessment?

A

ongoing during physical exam, part of general survey

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4
Q

skin structure?

A

epidermis
dermis
SUBQ

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5
Q

epidermal appendages?

A

hair
sebaceous glands
sweat glands (eccrine and apocrine)
nails

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6
Q

aging skin?

A

drier, thinner, flatter
decreased:
sebum/sweat
elasticity
functioning melanocytes
elastin/collagen
form new collagen
changes in:
temp regulation
nails
hair
circulation
skin lesions common
increased damage risk

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7
Q

effectors of skin condition?

A

thin
obese (skin folds)
fluid loss
excessive perspiration
diseases
inability to sense temp
nutrition deficits

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8
Q

health state effectors?

A

diabetes (more at risk for yeast infection, delayed wound healing)
GI probs
bed rest
casts
meds
lifestyle
piercings
urine/stool (can cause skin breakdown bc acidity)

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9
Q

skin integrity alterations?

A

external pressure- compresses BV
friction/shear- tear or injure BV or damages top layer
bony prominences- pressure ulcer
moisture
mental status
nutrition/hydration
age

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10
Q

braden scale categories?

A

sensory perception
moisture
activity
mobility
nutrition
friction and shear
1-4 scale (4 no impairment)

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11
Q

stage 1 pressure injury?

A

erythema of skin
nonblanchable
skin intact

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12
Q

stage 2 PI?

A

erythema with loss of partial thickness including epidermis and part of superficial dermis
presents as abrasion or blister

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13
Q

stage 3 PI?

A

full thickness, may involve SUBQ fat
presents as deep crater
skin completely gone

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14
Q

stage 4 PI?

A

full thickness, involves muscle or bone
tissue necrosis
“tunneling”

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15
Q

unstageable?

A

can’t stage, unknown deepness

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16
Q

Color classification: red?

A

protect*
proliferative stage and reflect healthy healing
interventions: gentle cleaning, moist dressing, changing dressing

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17
Q

Color classification: yellow?

A

cleanse*
may indicate exudate drainage or slough
oozing from tissue
drainage: whitish yellow, cream yellow, yellowish green, beige
interventions: irrigating, wet to moist dressing, nonadherent dressing, antimicrobial topicals

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18
Q

Color classification: black?

A

debride*
presence of eschar (necrotic tissue) brown, black, gray, tan
requires debridement (removal) for healing

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19
Q

eschar removal?

A

mechanical debridement? scalpel or scissors to cut dead tissue, scrub wound
chemical? collagenase enzyme agent or autolytic (helps body produce enzymes to break down)

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20
Q

wound/lesion documentation?

A

color
edges
size and shape
depth/tunnels/raised
odor
clock method
drainage
treatment method

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21
Q

subjective skin data?

A

previous hx
mole changes
pigment changes
excessive dryness or moisture
pruritus
excessive bruising

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22
Q

health hx questions?

A

rash/lesions
meds
hair loss
nail changes
environmental/occupational hazards
self care

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23
Q

objective data assessment supplies?

A

need:
gloves
tape/ruler
penlight
lighting

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24
Q

2 key components of physical exam? - what do you do?

A

inspection and palpation

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25
pallor?
pale
26
erythema?
red
27
cyanosis?
blue
28
jaundice?
yellow (excess bilirubin)
29
how to assess for inflammation?
palpate for edema and warmth
30
jaundice assessment for darker skin?
sclera/conjunctivae and mucous membranes (eyes and inside mouth)
31
petechia?
small red dots (bruising) from burst capillaries
32
how to assess temp?
back (dorsum) of hand hypothermia: low temp hyperthermia: high temp
33
moisture abnorms?
diaphoresis: excessive sweating dehydration (skin turgor)
34
inspect and palpate for?
texture thickness edema mobility/turgor vascularity bruising
35
tests for edema?
protein: keeps fluid in vascular system malnourished=hypoprotein use liver panel (albumin and complete protein) if a lot of fluid (swollen, ascites) anasarca? overall fluid state
36
assess lesions for?
color elevation pattern/shape size location distribution exudate
37
assess hair for?
color texture distribution lesions
38
assess nails for?
shape/contour consistency color cap refill (under 3= brisk, over 3= sluggish)
39
ABCDE rule?
asymmetry border color diameter elevation
40
annular/circular?
begins in center, spreads around periphery- larger over time
41
confluent?
run together
42
discrete?
distinct and separate
43
grouped?
clustered
44
gyrate?
twisted, coiled, snakelike
45
target?
"bullseye" concentric rings ex. lyme, tics
46
linear?
scratch, line, streak
47
polycyclic?
annular that grow together
48
zosteriform?
linear arrangement follows unilateral nerve route
49
purpura?
confluent and extensive patch of petechiae (less than 4 mm) and ecchymosis (larger than 1 cm)
50
hematoma?
bad bruise with pooling blood
51
necrosis?
cell death
52
striae?
dermal scarring (stretch marks)
53
macule?
solely color change, flat, less than 1 cm ex. freckles
54
patch?
macule larger than 1 cm ex. vitiligo
55
papule?
elevated, less than 1 cm ex. mole
56
plaque?
papules coalesce ex. psoriasis
57
nodule?
solid, elevated, larger than 1 cm ex. fibroma
58
wheal?
superficial, raised, slightly irregular ex. mosquito bite
59
vesicle?
elevated cavity containing free fluid ex. blister
60
cyst?
encapsulated fluid filled cavity
61
pustule?
turbid fluid in cavity (pus) ex. acne
62
crust?
thickened, dried exudate ex. scab
63
scale?
compact desiccated flakes ex. psoriasis
64
fissure?
linear crack ex. cheilosis (cracks in mouth corners)
65
excoriation?
inflammation from friction or reaction- self inflicted ex. scabies
66
keloid?
benign excess scar tissue ex. surgery, acne, piercings
67
what can lead to clubbing?
long term hypoxia from COPD (hypoperfusion to extremities)
68
abdomen checklist?
inspection: contour, symmetry, umbilicus, skin, pulsation auscultation: bowel sounds percussion: all four quadrants and liver/spleen borders palpation: light and deep