Integumentary System Assessment Flashcards
Any break or disruption of the skin predisposes the client to __________.
infection
The hydration of the skin and mucous membranes reveals the body’s ability to __________.
regulate body temperature
Skin temperature changes can reflect __________.
alterations in blood flow
Specific skin conditions or __________ may be detected.
underlying diseases
Condition of the skin reflects the level of a person’s __________.
hygiene
- Patient must be ___________ in an examining gown.
- __________
• Preferably natural illumination or bright overhead fluorescent lighting - A __________ examiner
• Hair, nails, and mucocutaneous regions must be included
(1) complete undressed but dressed
(2) Adequate illumination
(3) thorough
• Inspect skin (1) ________, ________, ________ and ________.
• Check skin (2) ________.
• Be alert for skin (3) ________.
• Evaluate hair (4) ________, ________ or ________.
• Note (5) ________ condition and ________.
(1) color, temperature, moisture, texture
(2) integrity
(3) lesions
(4) condition, loss or unusual growth
(5) nail bed, capillary refill
TRUE OR FALSE:
CLIENT PREPARATION
• Ask the client to remove all clothing and jewelry then put on the examination gown.
• Ask the client to remove nail enamel, artificial nails, wigs, and hairpieces as appropriate.
• Provide clear and appropriate instructions.
TRUE
CLIENT PREPARATION
• Position: (1) ________ on the examination table or bed; (2) __________ for assessing skin on buttocks and (3) ________ surfaces of legs.
(1) sitting
(2) lateral or prone
(3) dorsal
WHAT ARE THE PRIMARY LESIONS?
• Macule
• Patch
• Papule
• Plaque
• Pustule
• Vesicle
• Bulla
• Wheal
• Cyst
• Nodule
• Tumor
WHAT ARE THE SECONDARY LESIONS?
• Fissure
• Erosion
• Ulcer
• Scales
• Crust
• Keloid
• Atrophy
• Lichenification
• Inspect general skin coloration.
• While inspecting skin coloration, note any odors emanating from the skin.
• Melanin pigments account for skin color intensity.
INSPECTION
• While inspecting skin (1) ________, note any ________ emanating from the skin.
• (2) ________ pigments account for skin color intensity.
(1) coloration; odors
(2) Melanin
- a skin condition characterized by areas of dark, velvety discoloration in body folds and creases
- affected skin can become thickened
- often affects armpits, groin and neck
ACANTHOSIS NIGRICANS
- a disease in which the pigment cells of the skin, melanocytes, are destroyed in certain areas resulting to loss of skin color in the form of depigmented, or white, patches of skin in any location on the body
VITILIGO
CONDITION: Increased amount of deoxygenated hemoglobin, associated with hypoxia
CAUSE: Heart or lung disease; cold environment
LOCATION: Nail beds; lips; mouth; skin
Cyanosis (bluing)
CYANOSIS ASSESSMENT LOCATIONS:
Nail beds - (1) __________
Lips
Mouth
Skin - severe cases of (2) __________
(1) peripheral cyanosis
(2) central cyanosis
Reduced amount of oxyhemoglobin caused by ANEMIA
Pallor (decrease in skin color)
Reduced visibility of oxyhemoglobin as a result of decreased blood flow caused by SHOCK
Pallor (decrease in skin color)
Congenital or autoimmune condition causing lack of pigment caused by VILITGO
Pallor (decrease in skin color)
Skin color caused by anemia, shock, or vitiligo
Pallor (decrease in skin color)
ASSESSMENT LOCATION FOR PALLOR CAUSED BY ANEMIA
Face; conjunctiva; nailbeds
ASSESSMENT LOCATION FOR PALLOR CAUSED BY SHOCK
Skin; nail beds; conjunctiva; lips
ASSESSMENT LOCATION FOR PALLOR CAUSED BY VITILIGO
Patchy areas on the skin
- Hands, fingertips, or feet turn blue because they are not getting enough oxygen-rich blood.
- Cold temperatures, circulation problems, and tight jewelry are common causes
PERIPHERAL/ ACROCYANOSIS CYANOSIS
Generalized bluish discoloration of the body and the visible mucous membranes, which occurs due to inadequate oxygenation secondary to conditions that lead to an increase in deoxygenated hemoglobin or presence of abnormal hemoglobin
CENTRAL CYANOSIS
A rare clinical syndrome characterized by a triad of redness, warmth, and burning pain, most notably affecting the extremities.
ERYTHROMELALGIA
A condition that causes the blood vessels in the extremities to narrow, restricting blood flow.
RAYNAUD’S PHENOMENON
CONDITION: Increase deposition of bilirubin in the tissues
CAUSED BY: Liver, gallbladder, or pancreatic disease; destruction of RBC
ASSESSMENT LOCATION: Sclera; mucous membranes; skin
Jaundice (yellow-orange)
CONDITION: Increased visibility of oxyhemoglobin as a result of dilation or increased blood flow
CAUSED BY:Fever; direct trauma; blushing; alcohol intake
ASSESSMENT LOCATIONFace; area of trauma
Erythema (redness)
CONDITION: Increased amount of melanin
CAUSED BY: Suntan; pregnancy or Addison’s disease
ASSESSMENT LOCATION: Areas exposed to sun; face; areola; nipples
Tan-brown
CONDITION: Extravasation of blood into the subcutaneous tissue
CAUSED BY: Trauma or fragile blood vessels
ASSESSMENT LOCATION: Extremities, head, or trunk in areas easily exposed to injury
Ecchymosis (black and blue)
Is classically seen with hyperpigmentation due to Adrenocorticotropic Hormone melanogenesis.
Addison’s Disease
Also known as hyperbilirubinemia, is defined as a yellow discoloration of the body tissue resulting from the accumulation of excess bilirubin.
Jaundice
An inherited condition that affects the production of melanin, the pigment that colors the skin, hair and eyes.
ALBINISM
Characterized by persistent scaly plaques on the scalp, face, and ears which subsequently can progress to scarring, atrophy, dyspigmentation, and permanent hair loss in affected hair-bearing areas.
DISCOID LUPUS ERYTHEMATOSUS
• Some risk factors for skin breakdown leading to pressure ulcers include:
• Poor (1) __________
• Poor (2) __________
• Infrequent (3) __________
• (4) __________
• (5) __________
• (6) __________
(1) circulation
(2) hygiene
(3) position changes
(4) Dermatitis
(5) Infection
(6) Traumatic wounds
STAGING OF PRESSURE ULCERS
- Persistent nonblanchable erythema of intact skin. In darker skintones, ulcer may appear with persistent red, blue, or purple tones. Most common of all pressure ulcers.
- “At risk” person
STAGE I
STAGING OF PRESSURE ULCERS
- Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents as an erosion, blister, or vesicle.
STAGE II
STAGING OF PRESSURE ULCERS
- Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
STAGE III
STAGING OF PRESSURE ULCERS
- Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule).
- Undermining and sinus tracts may also be present
STAGE IV
• Inspect for __________
•Inspect localized parts of the body, noting any ___________.
color variations
•Check (1) __________
• Give special attention to (2) __________.
• Use a scale to document the degree of (3) __________ if present.
• For (4) __________ clients: inspect skin on limbs, under breasts, & in the groin area.
(1) skin integrity
(2) pressure point areas
(3) skin breakdown
(4) obese
A. DESCRIPTION
• Note the type of lesions
• (1) __________ – original lesions from previously normal skin
• (2) __________ – originates from primary skin lesions
• (3) __________ – lesions associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic diseases
• Note the color
• (4) __________
• (5) __________
(1) Primary
(2) Secondary
(3) Vascular skin lesions
(4) Diffused
(5) Circumscribed
A. DESCRIPTION
• Note (1) __________ (shape of individual lesions)
• Linear or serpiginous?
• Grouped or polycyclic?
• Annular or target-like?
• Note the (2) __________ of multiple lesions
• Discrete
• Confluent
• Randomized
• Note the (3) __________
(1) configuration
(2) arrangement
(3) size
CONFIGURATIONS OF LESIONS
- Individual and separate
- e.g. Insect bites
DISCRETE
CONFIGURATIONS OF LESIONS
- Lesions are clustered
- e.g. Herpes simplex
GROUPED
CONFIGURATIONS OF LESIONS
- Lesions merge and run together
- e.g. Childhood exanthema
CONFLUENT
CONFIGURATIONS OF LESIONS
- Lesions that form a line or snakelike shape
- e.g. Poison ivy, dermatitis, hookworm
LINEAR OR SERPINGINOUS
CONFIGURATIONS OF LESIONS
- Lesions arranged in a circular pattern
- e.g. Ringworm
ANNULAR
CONFIGURATIONS OF LESIONS
- Scattered over the body
- e.g. Measles
GENERALIZED
CONFIGURATIONS OF LESIONS
- Lesions arranged in concentric circles resembling a bullseye
- e.g. Eruptions from drug reactions, such as urticaria and erythema multiforme
POLYCYCLIC OR TARGETOID
CONFIGURATIONS OF LESIONS
- Linear arrangement along nerve root
- e.g. Herpes zoster
ZOSTERIFORM
• B.DISTRIBUTION
• Note the extent of (1) __________
• Localized or generalized?
• (2) __________
• Unilateral or bilateral?
• (3) __________
• Cleavage line
• Dermatomal line
(1) involvement
(2) Pattern or symmetry
(3) Characteristic Pattern
- Skin lesion that originates from previously normal skin
- Directly associated with a disease process
- Rarely specific to a single disease
PRIMARY SKIN LESIONS
- A circumscribed, flat lesion that differs from surrounding skin because of its color.
- May have any size or shape
- (1) ________: <1cm
- (2) ________: >1cm
(1) Macule
(2) Patch
> Freckles
Flat moles
Petechiae
Rubella
Vitiligo
Port wine stains
Ecchymosis
Macule and Patch
- Small, solid, elevated lesion less than 1 centimeter
- e.g. Elevated nevi, warts, or lichen planus
Papule
- Mesa-like elevation that occupies a relatively large surface area compared with its height.
- Size: Greater or equal to 1 cm
- e.g. Psoriasis, or actinic keratosis
Plaques
- Elevated, solid, palpable mass
- Depth of involvement, rather than diameter, differentiate a nodule from a papule
- 0.5-2cm; circumscribed
- e.g. Lipoma, squamous cell carcinoma, poorly absorbed injection, or dermatofibroma
Nodule
- A solid or cystic elevation or palpable lesion 2.0 cm or more in diameter
- Larger lipoma, or carcinoma
Tumor
- These are two types of blisters – circumscribed, elevated fluid- filled lesion which may contain serum, blood, lymph or extracellular fluid
- (1) __________: <1 cm
- (2) __________: >1 cm
(1) Vesicle
(2) Bulla
- Herpes Simplex/Zoster
- Varicella (Chickenpox)
- Poison Ivy
- Second-degree burn
Vesicles
- Pemphigus
- Contact dermatitis
- Large burn blisters
- Poison ivy
- Bullous impetigo
Bulla
- A.K.A. Hives or Urticaria
- Elevated mass with transient borders
- Rounded/flat topped elevated papule or plaque that characteristically disappears within hours
- Size and color vary
- Caused by movement of serous fluid into the dermis
- Does not contain free fluid in a cavity (e.g. vesicle)
- e.g. Urticaria (hives), or insect bites
Wheal
- Circumscribed, raised lesion containing purulent exudate
- Variable size or shape
- Variable color: white, yellow, greenish
- e.g. Acne, impetigo, furnucles, carbuncles
Pustule
Tract leading from a suppurative cavity to the skin surface or between cystic or abscess cavities
SINUS
- Encapsulated fluid-filled or semisolid mass
- Located in the subcutaneous tissue or dermis
- e.g. Sebaceous or Epidermoid
Cyst
- Typically result from evolution of primary lesions
- May be initiated by external forces (scratching, infection) or the healing process
SECONDARY SKIN LESIONS
- Loss of superficial epidermis
- Does not extend to the dermis
- Depressed, moist area
- e.g. Ruptured vesicles, scratch marks, apthous ulcer
Erosion
- Skin loss extending past epidermis
- Necrotic tissue loss
- Bleeding and scarring possible
Ulcer
- Skin mark left after healing of wound or lesion
- Represents replacement by connective tissue of the injured tissue
- Young _______: red or purple
- Mature _______: white or glistening
- e.g. Healed wound, healed surgical incision
Scar (Cicatrix)
- Linear crack in the skin
- May extend to the dermis
- e.g. Chapped lips or hands; athlete’s foot
Fissure
- Flakes secondary to desquamated, dead epithelium
- Flakes may adhere to skin surface
- Color varies (silvery, white)
- Texture varies (thick, fine)
- e.g. Dandruff, psoriasis, dry skin, or pityriasis rosea
Scales
- Dried residue of serum, blood, or pus on skin surface
- Large adherent crust is a scab
- e.g. Residue after vesicle rupture, impetigo, herpes, eczema
Crust
- Hypertrophied scar tissue
- Secondary to excessive collagen formation during healing
- Elevated, irregular, red
- Greater incidence in African Americans
- e.g. From ear piercing or surgical incision
Keloid
- Thin, dry, transparent appearance of epidermis
- Loss of surface markings
- Secondary to loss of collagen and elastin
- Underlying vessels may be visible
- e.g. Aged skin or arterial insufficiency
Atrophy
- Thickening and roughening of the skin
- Accentuated skin markings
- May be secondary to repeated rubbing, irritation, scratching
- e.g. Exposure to aero allergens, chemicals, foods, and emotional stress
Lichenification
WHAT ARE THE VASCULAR SKIN LESIONS?
• Petechia (Petechiae – plural)
• Ecchymosis (Ecchymoses – plural)
• Hematoma
• Cherry Angioma
• Spider Angioma
• Telangiectasis (Venous Star)
• Round red or purple macule
• Small: 1-2 mm
• Secondary to blood extravasation
• Associated with bleeding tendencies or emboli to skin
Petechia (Petechiae – plural)
• Round or irregular macular lesion
• Larger than petechia
• Color varies and changes: black, yellow, and green hues
• Secondary to blood extravasation
• Associated with trauma, bleeding tendencies
Ecchymosis (Ecchymoses – plural)
• A localized collection of blood creating an elevated ecchymosis
• Associated with trauma
Hematoma
• Papular and round
• Red or purple
• Noted on trunk, extremities
• May blach with pressure
• Normal age-related skin alteration
• Usually not clinically significant
Cherry Angioma
• Red, arteriole lesion
• Central body with radiating branches
• Noted on face, neck, arms, trunk
• Rare below waist
• May blanch with pressure
• Associated with liver disease, pregnancy and vitamin B deficiency
Spider Angioma
• Shape varies: spiderlike or linear
• Color bluish or red
• Does not blanch when pressure is applied
• Noted on legs, anterior chest
• Secondary to superficial dilation of venous vessels and capillaries
• Associated with increased venous pressure states (varicosities)
Telangiectasis (Venous Star)
Is usually evaluated according to the mnemonic ABCDE
Malignant melanoma
Malignant melanoma is usually evaluated according to the mnemonic ABCDE:
• A: __________
• B: __________ that are irregular (uneven or notched)
• C: __________ variations
• D: __________ exceeding 1/8 to 1/4 of an inch
• E: __________
Assymetry
Borders
Color
Diameter
Elevated
PALPATION
• Note of consistency
– (1) __________: lip
– (2) __________: nose
– (3) __________: bony prominence
• (4) __________
– Smooth or rough?
• (5) __________
– Warm to touch or cold?
(1) Soft
(2) Doughy
(3) Hard
(4) Texture
(5) Temperature
ASSESSMENT SCALE FOR PITTING EDEMA
- Slight pitting, no visible distortion, disappears rapidly
1+
ASSESSMENT SCALE FOR PITTING EDEMA
- Somewhat deeper pit thatn 1+, no readily detectable distortion, diasppears in 10-15 seconds
2+
ASSESSMENT SCALE FOR PITTING EDEMA
- Pit noticeable deep, may last more than a minute; the dependent extremity looks fuller and swollen
3+
ASSESSMENT SCALE FOR PITTING EDEMA
- Pit very deep, lasts 2-5 mins; dependent extremity is grossly distorted
4+
Rarely used method in the physical assessment of the integumentary system
PERCUSSION
• MAY BE USED IN SPECIAL CASES (E.G. FOR BRUIT ESPECIALLY HEMANGIOMAS)
AUSCULTATION
TRUE OR FALSE:
HAIR & SCALP ASSESSMENT
• Inspect for general color and condition.
•Inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions.
• Inspect amount and distribution of scalp, body, axillae, and pubic hair.
TRUE
TRUE OR FALSE:
NAIL ASSESSMENT
• Inspect nail grooming and cleanliness.
• Inspect nail color and markings.
• Inspect shape of nails.
TRUE
-Transverse depression in nails indicating temporary disturbance of nail growth (nails grow over for several months)
CAUSES:
- Acute illness
- Systemic illness such as severe infection or
nail injury
BEAU’S LINES
- Concave curvature of the nails
CAUSES:
- Iron-deficiency anemia
- Syphilis
- Use of strong detergents
KOILONYCHIA
- Early clubbing (180 degrees)
- Late clubbing (> 180 degrees)
- Change in angle between nail and nail base; nail bed softening, with nail flattening often
CAUSES:
- Chronic lack of oxygen due to heart or any pulmonary disease
CLUBBING
- Pit formation on the nails
CAUSES:
- Psoriasis
PITTING
- Red or brown linear streaks in nail bed
CAUSES:
- Minor trauma
- Subacute Bacterial Endocarditis
- Trichinosis
SPLINTER HEMORRHAGES
- Inflammation of skin at the base of the nail
CAUSES:
- Local infection
- Trauma
PARONYCHIA
NAIL ASSESSMENT
• Palpate nail to assess (1) __________.
• Palpate to assess the texture and consistency, noting whether (2) ________ is attached to _________.
• Test (3) __________ in nailbeds by pressing the nail tip briefly and watching for color change.
(1) texture
(2) nailplate / nailbed
(3) capillary refill
Lifespan Considerations
• Infants and children
• Newborn skin is covered with (1) __________.
• Infants have skin that is thin, soft, and free of (2) __________.
• (3) ________ and ________ are common, harmless markings in newborns.
(1) vernix caseosa
(2) terminal hair
(3) Milia and “Stork bites”
Lifespan Considerations
• Infants and children
• Infants may be born with (1) _________ present
• (2) ___________ is inefficient in infants.
• (3) ___________
• Gray, blue, or purple spots in the sacral and buttocks area
• Fade by age 3
(1) lanugo
(2) Temperature regulation
(3) Mongolian spots
Lifespan Considerations
• The pregnant female
• (1) ___________ increases.
• Areolae, nipples, vulva, perianal area
• Development of melasma and the linea nigra are common.
• (2) ___________ may cause oil and sweat glands to become hyperactive.
• Worsening acne in the first trimester
• Hair may fall out during months (3) __________.
(1) Skin pigmentation
(2) Hormonal changes
(3) 1–5
Lifespan Considerations
• The older adult
• (1) __________ decreases with aging.
• (2) __________ decreases and causes dryness.
• Perspiration (3) _________.
• The older adult
– Decrease in (4) __________ resulting in graying hair
– Increased sensitivity to (5) _________
– (6) _________ tend to become thicker and more brittle.
(1) Skin elasticity
(2) Sebum production
(3) decreases
(4) melanin production
(5) sunlight
(6) Nails
Psychosocial Considerations
• Stress-induced illnesses
• (1) __________
• Hair twisting or plucking
• (2) __________
• Visible skin disorders in relation to (3) _________
(1) Trichotillomania
(2) Nail biting
(3) self-esteem/body image
• Readiness for enhanced skin, hair, and nail integrity related to healthy hygiene and skin care practices, avoidance of overexposure to sun
Wellness Diagnoses
Requests information on skin reactions and effects of using a sun-tanning lotion
Health-Seeking Behavior
• Risk for __________ related to excessive exposure to cleaning solutions and chemicals
impaired skin integrity
• Risk for __________ related to prolonged sun exposure
impaired skin integrity
• Risk for __________ related to immobility, decreased production of natural oils, and thinning skin
imbalanced body temperature
• Risk for __________ related to thickened, dried toenails
impaired skin integrity of toes
• Risk for __________ related to severe diaphoresis
imbalanced body temperature
• Risk for __________ related to scratching of rash
infection
• Risk for __________ related to prolonged used of nail polish
impaired nail integrity
• Risk for __________: Less than body requirements related to increased vitamine and protein requirements necessary for healing of wound.
altered nutrition
• __________ related to lack of hygienic care of the skin, hair and nails
Ineffective health maintenance
• __________ related to immobility and decreased circulation
Impaired skin integrity
• __________ related to poor nutritional intake and bowel/bladder incontinence
Impaired skin integrity
• __________ related to scarring, rash, or other skin condition that alters skin appearance
Disturbed body image
• __________ related to persistent itching of the skin
Disturbed sleep pattern
• __________ related to excessive diaphoresis secondary to excessive exercise and high environmental temperatures
Deficient fluid volume
TRUE OR FALSE:
Health Teachings for Skin,
- Tell the client to apply alcohol-containing lotion and moisturizer regularly to the skin
FALSE
It should be ALCOHOL-FREE lotion and moisturizer
TRUE OR FALSE:
Health Teachings for Nails
- Instruct the client to cut nails only after soaking them at least 10 minutes in warm water.
TRUE
TRUE OR FALSE:
Health Teachings for Nails
- Caution client against the use of OTC preparations to treat corns, calluses, or ingrown toenails.
TRUE
TRUE OR FALSE:
Health Teachings for Nails
- Tell client to cut nails straight across and even with tops of fingers and toes. If client has Diabetes Mellitus, tell client to cut nails regularly.
FALSE
If the client has Diabetes Mellitus, tell the client to FILE and not cut the nails
