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