chap 14 Flashcards
skin is important because
provides a physical barrier that protects underlying tissues & organs
3 layers of skin
- epidermis
- dermis
- subcutaneous tissue
types of hair
- vellus
- terminal
purpose of hair
filters dust and airborne debris
lunula (nail)
white portion of nail
functions of nails
- protect distal end of fingers/toes
- enhance precise movement
- allow extended precision grip
subjective data of health assessment
- history of present health concerns
- personal health history
- family history
- lifestyle/health practices
personal health history
- sunburns
- current/previous skin prob
- hospitalizations
- surgery
- allergic reaction
- recent viral/bacterial infection
- pregnancy
- self-injury
family history
- recent illness, rash, other skin problems
- skin cancer
- keloids
inspection (skin assessment)
- color or color variations
- integrity
- lesions
palpation (skin assessment)
- texture
- thickness
- moisture
- temp
- mobility & turgor
- edema
Braden scale
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction & shear
perfect braden scale score
23
mild risk braden scale score
15-18
moderate risk braden scale score
13-14
high risk braden scale score
10-12
severe risk braden scale score
less than/equal to 9
what does the braden scale measure
pressure sore risk
hair (objective data)
- color
- condition
- texture
- distribution
- loss
- unusual growth patterns
nails (objective data)
- grooming
- color
- markings
- shape
- palpate for texture
- capillary refill
common nursing diagnoses
- readiness for enhanced health management
- risk for infection
- risk for imbalanced nutrition
- impaired skin integrity
- ineffective health maintenance
- disturbed body image
aging consideration
- decreased perspiration
- sebum decreases
- pale
- skin lesions
- loss of turgor
- sagging/wrinkles
- coarse hair
- nails become thicker, yellow, brittle
pressure ulcers
sores on skin @ pressure points
contributing factor to pressure ulcers
unrelieved pressure
high risk for pressure ulcers
critical care, long-term care facilities, patients on bedrest
stage 1 pressure ulcer
intact skin w/ non-blanchable redness
- painfull
- firm or soft
- warm or cooler than adjacent tissue
stage 2 pressure ulcer
shallow open ulcer w/ pink wound bed
- intact/open blister
- shiny/dry shallow ulcer
- no slough or bruising
stage 3 pressure ulcer
full thickness tissue loss
- slough may be present
- may have tunneling
- bone/tendon NOT visible
stage 4 pressure ulcer
full thickness loss w/ bone/tendon/muscle exposed
- slough present
- tunneliing
What is the greatest risk for MRSA
impaired skin integrity
most common cancer
skin cancer
types of skin cancer
- melanoma
- basal cell carcinoma
- squamous cell carcinoma
ABCDE assessment
a- asymmetry b-borders c-color variations d-diameter e-evolution
risk factors for skin cancer
- sun exposure/tanning
- family history
- moles
- fair skin (burns/freckles easily)
- age
macule
darkened area that is flat
papule
raised area, knotty looking, sometimes pain
vesicle
fluid filled, blister
wheal
raised, red areas, allergic-type reaction
pustule
pus-filled lesions
petechia
- type of macule
- round red/purple
- associated w/ bleeding tendencies
- flat
ecchymosis
bruising
ridging in nail
- can be normal
- can be indicative of nutritional problem
koilonychia
- seen in iron-deficiency anemia
- endocrine & cardiac disease
- “spoon-shaped”
