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Nursing Assesment > Integumentary System > Flashcards

Integumentary System Flashcards

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1
Q

Physical assessment approach

A

Head to toe, anterior, posterior and lateral

Or by region as other systems are assessed

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2
Q

Physical assessment techniques for integumentary system

A

Inspection and palpation

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3
Q

Inspection of the skin should look at..

A

Color
Odor
Integrity
Any lesions

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4
Q

Pallor

A

An unhealthy pale appearance

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5
Q

Erythema

A

Flushed appearance, redness

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6
Q

Pediculosis

A

Infection of the hair follicles

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7
Q

Normal base angle of nails =

A

160 degrees

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8
Q

Atrophic

A

Thinning

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9
Q

+1 edema

A

Mild (2mm)

No perceptual swelling

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10
Q

+2 edema

A

Moderate (4mm)

Indentation subsides quickly

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11
Q

+3 edema

A

Severe (6mm)

Indentation remains for a short time, leg looks swollen

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12
Q

+4 edema

A

Pitting (8 mm)

Indentation lasts for a long time

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13
Q

Normal skin elasticity test =

A

Brisk turgor

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14
Q

Occiput

A

Back of head

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15
Q

Indurated

A

Elevated, defined borders (usually red)

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16
Q

Granular

A

Little tiny bumps

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17
Q

Erythematous

A

Red

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18
Q

Pedunculation

A

Skin tags

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19
Q

Exudate

A

Fluid

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20
Q

Cellulitis

A

Infection of the skin

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21
Q

Annular

A

Circular (freckle, mole, ulcer)

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22
Q

Confluent

A

When things merge together and touch each other

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23
Q

Discrete

A

Singular and separate from one another

24
Q

Gyrate

A

More of a coil or S-like pattern

25
Q

Grouped

A

Many lesions in one area (hives, freckles, burns)

26
Q

Linear

A

Follows one track (spider bites, burns, incisions)

27
Q

Target

A

Looks like a bulls-eye (usually bug bite, sometimes burn)

28
Q

Zosteriform

A

Relatively specific to shingles virus, follows neurological tract

29
Q

Two types of lesions

A

Primary & secondary

30
Q

Primary lesion

A

Initial alteration of the skin

31
Q

Secondary lesion

A

Arises from a change in primary lesion

32
Q

Macule

A

Solely a color change, flat and circumscribed, less than 1 cm

33
Q

Examples of macules

A

Freckles, flat nevi, petechiae

34
Q

Petechiae

A

Pinpoint, round spots that appear on the skin as a result of bleeding

35
Q

Nevi

A

Birthmark or mole

36
Q

Patch

A

Macules that are larger than 1 cm

37
Q

Examples of patches

A

Mongolian spot, vitiligo, cafe au lait spot

38
Q

Papule

A

Something you can feel (i.e, solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis

39
Q

Examples of papules

A

Elevated nevus, wart (nevus)

40
Q

Plaque

A

Papules coalesce to form surface elevation wider than 1 cm

41
Q

Polycyclic

A

Many of them in one small area

42
Q

Examples of plaque

A

Psoriasis

43
Q

Melanoma assessment

A

Asymetry
Border
Color
Diameter

44
Q

Nodule characteristics

A 
Elevated
Firm 
Circumscribed lesion 
Deeper in dermis than papule 
>0.5cm in diameter
45
Q

Tumor

A

Elevated and solid lesion that may or may not be clearly demarcated deeper in the dermis
Greater than 2 cm in diameter

46
Q

Wheal

A

Superficial, raised, transient and erythematous, slightly irregular shape due to edema (fluid held diffusely in the tissues)

47
Q

Wheal examples

A

Mosquito bite, allergic reaction, dermographism

48
Q

Dermographism

A

Where skin is under reaction, usually from drug

49
Q

Urticaria is AKA

A

hives

50
Q

Urticaria

A

Wheals coalesce to form extensive reaction, usually pruritic

51
Q

Vesicle

A

Elevated cavity containing free fluid, up to 1 cm; a “blister”
Clear serum flows if wall is ruptured

52
Q

Examples of vesicles

A

Herpes simplex, early varicella (chickenpox), herpes zoster (shingles)

53
Q

Bulla

A

Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; thin walled-ruptures easily

54
Q

Examples of bulla

A

Friction blister, burns, contact dermatitis

55
Q

Pustule

A

Elevated, superficial lesion similar to vesicle but filled with purulent fluid
Circumscribed and elevated

56
Q

Pustule examples

A

Impetigo, acne

57
Q

Cyst

A

Elevated, circumscribed, encapsulated lesion in dermis or subcutaneous layer
Filled with liquid or semisolid material

Nursing Assesment (17 decks)

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