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1080 Holistic Health Assessment > Integumentary Assessment > Flashcards

Integumentary Assessment Flashcards

1
Q

Integumentary System

A
  • Skin, nails, hair & sweat glands
  • Reflection of hydration, nutrition & emotional status
  • Skin is 1st line of defence against environmental threats
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2
Q

Risk Factors of Integumentary Conditions

A
  • Nutrition status (vitamin/mineral deficiency)
  • Immobility (pressure, forces, friction)
  • UV exposure (natural & artificial)
  • Skin entry infectious diseases (manifestation/immunization)
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3
Q

Skin Health

A
  • Benign mole investigation
  • Skin self-examination
  • UV exposure (seek, slip, slap, slop)
  • Radiation (high risk for malignant skin cancers)
  • Vitamin D & tanning beds
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4
Q

Skin Layers

A
  • Epidermis
  • Dermis
  • Subcutaneous (hypodermis)
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5
Q

Melanoma Skin Cancer

A
  • Most dangerous skin cancer
  • Spreads in body
  • Less common
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6
Q

ABCDE of Melanoma

A
  • Asymmetry (shape difference on sides)
  • Border (visible edge is irregular, ragged, imprecise)
  • Colour (colour variation within legion)
  • Diameter (growth is normal <6mm)
  • Evolution (change in color, shape size & symptoms itching, tenderness, swelling)
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7
Q

Subjective Data Collection for Integumentary Assessment

A
  • Family history (melanoma history = higher risk)
  • Past history
  • Medications (allergies)
  • Lifestyle (occupational, personal behaviors)
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8
Q

Specific Questions for Integumentary Assessment

A
  • OLDCARTSS
  • Painful or itchy
  • Progression
  • Associated symptoms (fever, malaise)
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9
Q

Cyanosis

A
  • Blue tint
  • Lack of oxygen
  • Around nails/mouth
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10
Q

Pallor

A
  • Paleness
  • Decreased hemoglobin/anemia
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11
Q

Jaundice

A
  • Yellowing of skin
  • Underlying liver disorder
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12
Q

Erythema

A
  • redness
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13
Q

Edema

A
  • swelling on skin
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14
Q

Types of Primary Legions

A
  • Vesicle
  • Pustule
  • Cyst
  • Macule
  • Papule
  • Wheal
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15
Q

Configuration of Legions

A
  • Location of legions
  • Distribution (localized, regional, generalized)
  • Primary (initially appearing) or secondary (resulting from change to primary)
  • Shape & size
  • Margins/borders
  • Morphology (papule, plaque, pustule, bulla, macule)
  • Colour/pigmentation
  • Texture/consistency
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16
Q

Papule Legion

A
  • Raised legion
  • <1cm
  • Wart, insect bite
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17
Q

Plaque Legion

A
  • slightly raised
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18
Q

Bulla Legion

A
  • contains fluid
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19
Q

Macule Legion

A
  • Flat
  • <1cm
  • Freckles, tattoos
20
Q

Pustule Legion

A
  • Contains pus
  • Generally raised
  • Can be various sizes
  • Surface of skin
  • ACNE
21
Q

Vesicle Legion

A
  • Fluid filled blister
  • Various sizes depending on stage
  • Surface of skin
  • HERPES/CHICKEN POX
22
Q

Cyst Legion

A
  • Distinct walled off legion
  • Underneath skin
  • Fluid filled/semisolid
  • Could contain pus, cells, infection (palpation will confirm pus)
23
Q

Wheal Legion

A
  • Slightly raised (less than papule)
  • Flesh coloured/erythematous
  • Range between papules/plaques
  • Varies in shape & size
24
Q

Types of Secondary Legions

A
  • Scar
  • Ulcer
  • Excoriation
25
Q

Scar Legion

A
  • Overhealed skin
  • Raised
26
Q

Ulcer

A
  • Loss of skin surface
  • Extend into dermis, subcutaneous, fascia, muscle, bone
27
Q

Palpation of Legion

A
  • Access skin texture, moisture, temperature
  • Access skin turgor for hydration status (below clavicle)
  • Check lesions for tenderness, mobility & consistency
  • Hair & nails for brittleness
  • Presence of infection or drainage requires gloves
28
Q

Types of Rashes

A
  • Eczema
  • Fungal infection
  • Psoriasis
  • Cradle cap
  • Tinea Capitis
  • Trichotillomania
  • Subungual Hematoma
29
Q

Eczema

A
  • Dryness
  • Allergies/asthma
30
Q

Fungal Infection

A
  • Well circumscribed legion
  • With erythematous borders
31
Q

Psoriasis

A
  • Causes plaques & legions on skin
32
Q

Cradle Cap

A
  • Yellowing/crusting
  • Alleviates over time
33
Q

Trichotillomania

A
  • Mental health condition
  • Pulling out hair
  • No follicle breakage (grows back)
34
Q

Subungual Hematoma

A
  • Blood collects under toe(s)
  • Some sort of trauma inducement
35
Q

Pregnant Women Skin Conditions

A
  • Melasma, facial darkening related to hormonal changes (reversible)
  • Linea nigra, pregnancy line related to hormonal changes (resolve few months after pregnancy)
36
Q

Newborn/Infant Skin Conditions

A
  • Vernix, white substance covers baby in uterus
  • Stork bites, vascular collection of tissue (resolves in 1-2 years)
  • Mongolian spots, blemish bruise mark around sacrum
37
Q

Older Adult Skin Conditions

A
  • Sun damage to skin
  • Basal cell carcinoma, raised central ulceration
  • Actinic keratosis, precursor to squamous cell carcinoma (untreated)
  • Seborrheic keratosis, sun damage (non-cancerous growth on skin)
38
Q

Pressure Ulcer Assessment

A
  • Stages 1-4
  • Braden scale risk assessment
  • Repositioning every 2 hours
  • Break in skin = risk of infection
  • Can become septic
39
Q

Pressure Ulcer Stage 1

A
  • Intact skin
  • Non-blanchable redness of localized area (over bone)
  • May be painful, firm, soft, warm/cold compared to adjacent tissue
40
Q

Pressure Ulcer Stage 2

A
  • Partial thickness of dermis
  • Shallow opening with red/pink wound bed
  • Shiny/dry
  • No slough/bruising
41
Q

Pressure Ulcer Stage 3

A
  • Full thickness tissue loss
  • Visible fat
  • Slough present, not obscuring depth of tissue loss
  • May be undermining & tunneling
42
Q

Pressure Ulcer Stage 4

A
  • Full thickness tissue loss
  • Exposed bone, tendon, muscle
  • Visible/directly palpable
  • Slough/eschar present
  • Undermining & tunneling
43
Q

Prompt Evaluations & Interventions of Skin

A
  • Acute dehydration
  • Cyanosis
  • Impaired skin integrity
44
Q

Acute Trauma & Burns Stages

A
  • Intact skin
  • Partial thickness
  • Full thickness
  • Full thickness with exposure (bone/tendon)
45
Q

Rule of 9’s

A
  • Used for 2nd degree (partial thickness) & 3rd degree (full thickness)
  • Arms each 9%
  • Head & neck 9%
  • Front of body (chest & torso) 18%
  • Legs each 18%
  • Back of body 18%
  • Genitalia 1%

1080 Holistic Health Assessment (5 decks)

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