Ch.11 Integumentary/Skin Assessment Flashcards
melanoma detection
ACBDE
a: asymmetry
b: border irregularity
c: color
d: diameter of more than 6mm
e: evolution of lesion over time
what are common integumentary symptoms?
- pruritus: itching
- rash ( multiple lesions )
- single lesion or wound
abnormal integumentary findings
- skin:
➡️ pigmentation changes
➡️ lesions
➡️ infections
➡️ growths or tumors
➡️ wounds
➡️ skin breakdown - nails:
➡️ color, thickness & angle ( clubbing ) - hair:
➡️ color, consistency & distribution
what is the skin assessment of blanching
training to assess skin breakdown that incudes testing the skin’s blanch response to light finger pressure ( ex. assessing for stage I pressure ulcer, apply light pressure to the skin to note blanching ( whitening )
erythema
redness caused by irritation or stress
( in darker skin, redness may not be visible )
hyperpigmentation
increased pigmentation
hypopigmentation
reduced pigmentation
how many secs to check on a capillary refill?
5 seconds
how many secs to check the color back from the finger on the capillary refill?
2 seconds
cyanosis
5g/dL of unoxygenated hemoglobin in the arterial blood
➡️ central cyanosis ( cyanosis of the lips, mucous membranes, & tongue ) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels
cyanosis in different skin tones
- light-skinned: cyanosis presents as dark bluish tint to skin & mucous membranes
- dark-skinned: cyanosis presents as gray or whitish skin around the mouth; conjunctivae may appear gray or bluish
- in yellowish skin: cyanosis presents as grayish-greenish skin tone
wound healing phases
- inflammatory phase: begins within 30 minutes & last 2-3 days
- proliferative phase: begins at the end of the inflammatory phase may last up to 4 weeks
- remodeling phase: begins at the end of the proliferative phase & may last as long as 2 years
braden scale
- scoring scale for predicting pressure ulcer risk
- braden scores patients from 1-4 in each of six subscales: sensory perception, moisture, activity, mobility, nutrition, & frictions ( 14-18: high risk )
stage I pressure injury
intact skin with non-blanchable redness of a localised area usually over bony prominences
stage II pressure injury
partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough
stage III pressure injury
full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed
stage IV pressure injury
full thickness tissue loss with exposed bone, tendon or muscle
unstageable pressure injury
full thickness tissue loss in which the ulcer base is covered by slough ( yellow, tan, gray, green or brown ) and/or eschar ( tan, brown, or black ) in the wound bed
percentage of burn on head
9%
percentage of burn of anterior & posterior
both 18%: 36%
percentage of burn on humerus
9%
percentage of burn on groin
1%
percentage of burn on legs
18%
grade 1 edema
0-2 mm indentation; rebounds immediately
grade 2 edema
3-4 mm indentation; rebounds in <15 seconds
grade 3 edema
5-6 mm indentation
up to 30 seconds to rebound
grade 4 edema
8 mm indentation; > 20 seconds to rebound
lifespan considerations: older adults
- skin ages, loss of elastin, collagen, & subcutaneous fat
- decreased skin turgor ( elasticity of the skin )
- decreased melanin production
- thin brittle nails
urgent assessment
- acute dehydration, or cyanosis
- acute traumas that may include burns, large wounds
- not usually emergent
➡️ small lacerations
➡️ suspicious lesions
➡️ rash & fevers
subjective data collection
- assess the patient for potential risk factors
➡️ overall health
➡️ nutritional status
➡️ medications - health promotion & risk assessment
➡️ self skin assessment ( SSE )
➡️ patient education
photo-reactions
medications:
- anitmicrobials
- psychotropic & other psychiatric agents
- cardiovascular agents
- herbals & topical
- antihistamines
- disease-modifying agents
- hypoglycemic
- topical agents
- nonsteroidal anti-inflammatory drugs
objective data collection
- performed in a head to toe format
➡️ general skin assessment
➡️ assess the skin with inspection of each body area - color, temperature, moisture, turgor, texture
- assess & describe; wounds, lesions, rashes, hematomas
skin color basics
- pallor ( anemia )
- cyanosis ( hypoxemia )
- redness ( burns )
- color changes ( pressure ulcers )
review question #1: the nurse is admitting a 75 year old male with a 50 year history of smoking one pack of cigarettes per day. among the patient’s concerns is his chronic shortness of breath. one nail finding that demonstrates chronic hypoxia is?
clubbing
review question #2: all of the following skin lesions may be papular expect?
herpes zoster
review question #3: the ABCDEs of melanoma identification do not include?
birthmark ( correct term is border irregularity )
review question #4: a nurse observes a skin lesion with well-defined borders on the upper left thigh. it is 1.5 cm in diameter, flat, hypopigmented, & nonpalpable. what is the correct terminology for this lesion?
patch
review question #5: when assessing hydration, the nurse will?
pinch a fold of skin on the medial aspect of the forearm & observe for recoil to normal
review question #6: a fair skinned, blonde, 18 year old female is at the clinic for a skin examination. she reports that she always turns red within 10 minutes of going outside. she is planning a trip to mexico & wants to avoid getting sunburned. which of the following would be included in the teaching? ( select all that apply )
- excessive exposure to UVA & UVB rays increases risk of sunburn & skin cancer
- apply sunscreen or sunblock at least 15-30 minutes before sun exposure
- avoid sun exposure between 10 a.m.-4 p.m. to reduce UVA & UVB exposure
review question #7: a patient presents to the clinic with erythematous vesicles on the face & chest. some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. which of the following infectious illnesses does the nurse suspect?
varicella
review question #8: a 24 year old patient reports an itchy red rash under their breasts/chest. examination reveals large, reddened, moist patches under both breasts/chest in the skin folds. several smaller, raised, red lesions surround the edges of the larger patch. what is the correct terminology for the distribution pattern of these smaller lesions?
satellite
review question #9: a 22 year old patient present to the clinic with a large firm mass on their left earlobe. they had their ears pierced approximately 6 weeks ago. the mass began as a small bump & progressively enlarged to its current size of approximately 2.5 cm ( 1 inch ) in diameter. it is not tender, reddened, or seeping any drainage. what is the term used to describe this secondary skin lesion?
keloid
review question #10: an 83 year old female is undergoing a routine physical examination. which of the following assessment findings would the nurse consider an expected age-related variation?
thinning of the skin
review question #11: a patient has several red, inflamed, superificial, palpable lesions containing a thickened yellowish substance. how would the nurse document this lesion?
pustule
