NUR 362 - SKIN Flashcards
Function of the Skin
protection prevents penetration of microorganisms perception of sensory touch, pain, temperature temperature regulation identification communication (sign language, body posture) wound repair absorption/excretion of minerals production of vitamin D
Epidermis layer
outer layer
body’s main defense against infection
Dermis layer
thick layer below epidermis consisting of connective tissue
elastic tissue allowing stretch
nerves, sensory receptors, blood vessels, lymphatics
hair follicles, sweat glands, sebaceous glands
Subcutaneous layer
lobules of fat cells for energy
insulation for temperature control
protection by cushioning effect
Infant skin changes
lanugo (fine downy hair) replaced with fine vellus hair
vernix caseosa
thin, smooth, elastic skin
epidermis thickens as child grows
Adolescent skin changes
increased gland activity (apocrine, sebaceous) sexual development (secondary sex characteristics)
Elderly skin changes
skin loses elasticity, folds, and sags
outer layer of epidermis thins and flattens
loss of elastin, collagen, and subcutaneous fat
sweat and sebaceous glands decrease
senile purpura (vascularity of skin decreases)
sun exposure and smoking cause pigment changes
melanocytes decrease (gray hair)
Adult skin changes
dermis 20% thinner by 35 regeneration takes 40 days skin easily irritated sensory receptors dull vitamin d decreases immunity function decreases
Inspection of Skin
integrity color skin lesions (birthmarks, freckles, moles) tattoos, piercings hair fingernails vascularity or bruising
Palpation of Skin
temperature moisture texture thickness edema turgor hair nails
Primary skin lesions
arise from healthy skin tissue
macule, papule, nodule/tumor, vesicle, pustule, wheal
Secondary skin lesions
result from change in primary or injury
scale, ulcer
Macules/Patches
flat to the skin circumscribed change in skin color < 1 cm - macules > 1 cm - patches ex: freckles, Mongolian spots
Petechiae
leakage of blood into skin
smooth
nonblanchable
red, small, seen if person is on anti-coagulant and capillaries are releasing blood
Purpura
leakage of blood into skin
smooth
nonblanchable
range from red to purple, larger, bigger than petechiae (seen in vascular diseases)
Ecchymosis
leakage of blood into skin due to trauma/injury
smooth
nonblanchable
bruise
Papules
raised, palpable lesions < 1 cm circumscribed solid elevation ex: moles, warts
Nodules
1-2 cm
circumscribed
deeper
ex: lipoma
Vesicles and Bullae
vesicles < 1 cm bullae > 1 cm circumscribed fluid-filled Ex: blister
Pustules
vary in size
usually yellow-white in color
purulent filled
ex: acne, folliculitis
Plaques
> 1 cm
plateau-like elevation
scaly texture
ex: psoriasis
Wheals
vary in size
irregularly shaped
superficial
ex: hives
Patterns of lesions
discrete
diffuse
confluent
Pressure ulcers
area of skin breakdown that occurs secondary to constant pressure to one area
blood supply, oxygen and circulation reduced to area
Pressure ulcer assessment factors
location
length (length, width, depth) - always in cm
drainage (color, quality, odor, amount)
tracts, tunneling, undermining?
what does skin look like around wound? “peri-wound area”
Pressure Ulcer Stage 1
skin appears red but unbroken
localized redness doesn’t blanch
Pressure Ulcer Stage 2
partial-thickness skin erosion
loss of epidermis and/or dermis
ulcer looks shallow like abrasion or open blister
Pressure Ulcer Stage 3
full-thickness
extends into subcutaneous layer looking like a crater
peri-wound involvement
Pressure Ulcer Stage 4
full-thickness with extensive involvement of underlying structures
exposes muscles/tendons and/or bone
peri-wound involvement
drainage present
slough (dead skin)/necrotic tissue is common
Unstageable Pressure Ulcer
necrotic tissue or slough is covering base of the ulcer
Skin Cancer Assessment
Asymmetrical shape Border irregular Changes in color Diameter > 6 mm Evolving, elevation
Cause of pressure ulcers
pressure
friction
shear
moisture
Intrinsic pressure ulcer factors
things that the patient comes in with age disease immobility sensory loss body type poor nutrition infection incontinence
Extrinsic pressure ulcer factors
things that we do as healthcare providers incontinence excessive uniaxial pressure friction and shear force impact injury heat moisture posture
Braden scale
method of assessing the risk of pressure ulcers sensory perception moisture activity mobility nutrition friction and shear lower total score = higher risk
Braden scale scores
general trigger for potential pressure ulcer risk problem (max score 23)
below 16 is at risk
below 12 is high risk
Supine position ulcer areas
skull
shoulder/scapula
heel
elbow
Side-lying position ulcer areas
groin feet knee hip elbow wrist
Prone position ulcer areas
ear breast toe knee wrist
Wheelchair position ulcer areas
buttock heel knee shoulder/scapula back
Fowler’s position ulcer areas
heel toe wrist elbow scapula/shoulder head
