CH 13: Skin Hair Nails and Wounds Flashcards
what is the largest organ?
skin
what does skin do?
first line defense
protects
supports
adapts
when do you conduct skin assessment?
ongoing during physical exam, part of general survey
skin structure?
epidermis
dermis
SUBQ
epidermal appendages?
hair
sebaceous glands
sweat glands (eccrine and apocrine)
nails
aging skin?
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
effectors of skin condition?
thin
obese (skin folds)
fluid loss
excessive perspiration
diseases
inability to sense temp
nutrition deficits
health state effectors?
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)
skin integrity alterations?
external pressure- compresses BV
friction/shear- tear or injure BV or damages top layer
bony prominences- pressure ulcer
moisture
mental status
nutrition/hydration
age
braden scale categories?
sensory perception
moisture
activity
mobility
nutrition
friction and shear
1-4 scale (4 no impairment)
stage 1 pressure injury?
erythema of skin
nonblanchable
skin intact
stage 2 PI?
erythema with loss of partial thickness including epidermis and part of superficial dermis
presents as abrasion or blister
stage 3 PI?
full thickness, may involve SUBQ fat
presents as deep crater
skin completely gone
stage 4 PI?
full thickness, involves muscle or bone
tissue necrosis
“tunneling”
unstageable?
can’t stage, unknown deepness
Color classification: red?
protect*
proliferative stage and reflect healthy healing
interventions: gentle cleaning, moist dressing, changing dressing
Color classification: yellow?
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
Color classification: black?
debride*
presence of eschar (necrotic tissue) brown, black, gray, tan
requires debridement (removal) for healing
eschar removal?
mechanical debridement? scalpel or scissors to cut dead tissue, scrub wound
chemical? collagenase enzyme agent or autolytic (helps body produce enzymes to break down)
wound/lesion documentation?
color
edges
size and shape
depth/tunnels/raised
odor
clock method
drainage
treatment method
subjective skin data?
previous hx
mole changes
pigment changes
excessive dryness or moisture
pruritus
excessive bruising
health hx questions?
rash/lesions
meds
hair loss
nail changes
environmental/occupational hazards
self care
objective data assessment supplies?
need:
gloves
tape/ruler
penlight
lighting
2 key components of physical exam? - what do you do?
inspection and palpation
pallor?
pale
erythema?
red
cyanosis?
blue
jaundice?
yellow
(excess bilirubin)
how to assess for inflammation?
palpate for edema and warmth
jaundice assessment for darker skin?
sclera/conjunctivae and mucous membranes
(eyes and inside mouth)
petechia?
small red dots (bruising) from burst capillaries
how to assess temp?
back (dorsum) of hand
hypothermia: low temp
hyperthermia: high temp
moisture abnorms?
diaphoresis: excessive sweating
dehydration (skin turgor)
inspect and palpate for?
texture
thickness
edema
mobility/turgor
vascularity
bruising
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
assess lesions for?
color
elevation
pattern/shape
size
location
distribution
exudate
assess hair for?
color
texture
distribution
lesions
assess nails for?
shape/contour
consistency
color
cap refill (under 3= brisk, over 3= sluggish)
ABCDE rule?
asymmetry
border
color
diameter
elevation
annular/circular?
begins in center, spreads around periphery- larger over time
confluent?
run together
discrete?
distinct and separate
grouped?
clustered
gyrate?
twisted, coiled, snakelike
target?
“bullseye” concentric rings
ex. lyme, tics
linear?
scratch, line, streak
polycyclic?
annular that grow together
zosteriform?
linear arrangement follows unilateral nerve route
purpura?
confluent and extensive patch of petechiae (less than 4 mm) and ecchymosis (larger than 1 cm)
hematoma?
bad bruise with pooling blood
necrosis?
cell death
striae?
dermal scarring (stretch marks)
macule?
solely color change, flat, less than 1 cm
ex. freckles
patch?
macule larger than 1 cm
ex. vitiligo
papule?
elevated, less than 1 cm
ex. mole
plaque?
papules coalesce
ex. psoriasis
nodule?
solid, elevated, larger than 1 cm
ex. fibroma
wheal?
superficial, raised, slightly irregular
ex. mosquito bite
vesicle?
elevated cavity containing free fluid
ex. blister
cyst?
encapsulated fluid filled cavity
pustule?
turbid fluid in cavity (pus)
ex. acne
crust?
thickened, dried exudate
ex. scab
scale?
compact desiccated flakes
ex. psoriasis
fissure?
linear crack
ex. cheilosis (cracks in mouth corners)
excoriation?
inflammation from friction or reaction- self inflicted
ex. scabies
keloid?
benign excess scar tissue
ex. surgery, acne, piercings
what can lead to clubbing?
long term hypoxia from COPD (hypoperfusion to extremities)
abdomen checklist?
inspection: contour, symmetry, umbilicus, skin, pulsation
auscultation: bowel sounds
percussion: all four quadrants and liver/spleen borders
palpation: light and deep
