CH 13: Skin Hair Nails and Wounds

Question 1

what is the largest organ?

Answer 1

skin

Question 2

what does skin do?

Answer 2

first line defense
protects
supports
adapts

Question 3

when do you conduct skin assessment?

Answer 3

ongoing during physical exam, part of general survey

Question 4

skin structure?

Answer 4

epidermis
dermis
SUBQ

Question 5

epidermal appendages?

Answer 5

hair
sebaceous glands
sweat glands (eccrine and apocrine)
nails

Question 6

aging skin?

Answer 6

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

Question 7

effectors of skin condition?

Answer 7

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

Question 8

health state effectors?

Answer 8

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)

Question 9

skin integrity alterations?

Answer 9

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

Question 10

braden scale categories?

Answer 10

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

Question 11

stage 1 pressure injury?

Answer 11

erythema of skin
nonblanchable
skin intact

Question 12

stage 2 PI?

Answer 12

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

Question 13

stage 3 PI?

Answer 13

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

Question 14

stage 4 PI?

Answer 14

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

Question 15

unstageable?

Answer 15

can’t stage, unknown deepness

Question 16

Color classification: red?

Answer 16

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

Question 17

Color classification: yellow?

Answer 17

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

Question 18

Color classification: black?

Answer 18

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

Question 19

eschar removal?

Answer 19

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

Question 20

wound/lesion documentation?

Answer 20

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

Question 21

subjective skin data?

Answer 21

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

Question 22

health hx questions?

Answer 22

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

Question 23

objective data assessment supplies?

Answer 23

need:
gloves
tape/ruler
penlight
lighting

Question 24

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

Answer 24

inspection and palpation

Question 25

pallor?

Answer 25

pale

Question 26

erythema?

Answer 26

red

Question 27

cyanosis?

Answer 27

blue

Question 28

jaundice?

Answer 28

yellow (excess bilirubin)

Question 29

how to assess for inflammation?

Answer 29

palpate for edema and warmth

Question 30

jaundice assessment for darker skin?

Answer 30

sclera/conjunctivae and mucous membranes (eyes and inside mouth)

Question 31

petechia?

Answer 31

small red dots (bruising) from burst capillaries

Question 32

how to assess temp?

Answer 32

back (dorsum) of hand hypothermia: low temp hyperthermia: high temp

Question 33

moisture abnorms?

Answer 33

diaphoresis: excessive sweating dehydration (skin turgor)

Question 34

inspect and palpate for?

Answer 34

texture thickness edema mobility/turgor vascularity bruising

Question 35

tests for edema?

Answer 35

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

Question 36

assess lesions for?

Answer 36

color elevation pattern/shape size location distribution exudate

Question 37

assess hair for?

Answer 37

color texture distribution lesions

Question 38

assess nails for?

Answer 38

shape/contour consistency color cap refill (under 3= brisk, over 3= sluggish)

Question 39

ABCDE rule?

Answer 39

asymmetry border color diameter elevation

Question 40

annular/circular?

Answer 40

begins in center, spreads around periphery- larger over time

Question 41

confluent?

Answer 41

run together

Question 42

discrete?

Answer 42

distinct and separate

Question 43

grouped?

Answer 43

clustered

Question 44

gyrate?

Answer 44

twisted, coiled, snakelike

Question 45

target?

Answer 45

"bullseye" concentric rings ex. lyme, tics

Question 46

linear?

Answer 46

scratch, line, streak

Question 47

polycyclic?

Answer 47

annular that grow together

Question 48

zosteriform?

Answer 48

linear arrangement follows unilateral nerve route

Question 49

purpura?

Answer 49

confluent and extensive patch of petechiae (less than 4 mm) and ecchymosis (larger than 1 cm)

Question 50

hematoma?

Answer 50

bad bruise with pooling blood

Question 51

necrosis?

Answer 51

cell death

Question 52

striae?

Answer 52

dermal scarring (stretch marks)

Question 53

macule?

Answer 53

solely color change, flat, less than 1 cm ex. freckles

Question 54

patch?

Answer 54

macule larger than 1 cm ex. vitiligo

Question 55

papule?

Answer 55

elevated, less than 1 cm ex. mole

Question 56

plaque?

Answer 56

papules coalesce ex. psoriasis

Question 57

nodule?

Answer 57

solid, elevated, larger than 1 cm ex. fibroma

Question 58

wheal?

Answer 58

superficial, raised, slightly irregular ex. mosquito bite

Question 59

vesicle?

Answer 59

elevated cavity containing free fluid ex. blister

Question 60

cyst?

Answer 60

encapsulated fluid filled cavity

Question 61

pustule?

Answer 61

turbid fluid in cavity (pus) ex. acne

Question 62

crust?

Answer 62

thickened, dried exudate ex. scab

Question 63

scale?

Answer 63

compact desiccated flakes ex. psoriasis

Question 64

fissure?

Answer 64

linear crack ex. cheilosis (cracks in mouth corners)

Question 65

excoriation?

Answer 65

inflammation from friction or reaction- self inflicted ex. scabies

Question 66

keloid?

Answer 66

benign excess scar tissue ex. surgery, acne, piercings

Question 67

what can lead to clubbing?

Answer 67

long term hypoxia from COPD (hypoperfusion to extremities)

Question 68

abdomen checklist?

Answer 68

inspection: contour, symmetry, umbilicus, skin, pulsation auscultation: bowel sounds percussion: all four quadrants and liver/spleen borders palpation: light and deep