NUR 362 - SKIN

Question 1

Function of the Skin

Answer 1

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

Question 2

Epidermis layer

Answer 2

outer layer

body’s main defense against infection

Question 3

Dermis layer

Answer 3

thick layer below epidermis consisting of connective tissue
elastic tissue allowing stretch
nerves, sensory receptors, blood vessels, lymphatics
hair follicles, sweat glands, sebaceous glands

Question 4

Subcutaneous layer

Answer 4

lobules of fat cells for energy
insulation for temperature control
protection by cushioning effect

Question 5

Infant skin changes

Answer 5

lanugo (fine downy hair) replaced with fine vellus hair
vernix caseosa
thin, smooth, elastic skin
epidermis thickens as child grows

Question 6

Adolescent skin changes

Answer 6

increased gland activity (apocrine, sebaceous)
sexual development (secondary sex characteristics)

Question 7

Elderly skin changes

Answer 7

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)

Question 8

Adult skin changes

Answer 8

dermis 20% thinner by 35 
regeneration takes 40 days
skin easily irritated
sensory receptors dull
vitamin d decreases
immunity function decreases

Question 9

Inspection of Skin

Answer 9

integrity
color 
skin lesions (birthmarks, freckles, moles)
tattoos, piercings
hair
fingernails
vascularity or bruising

Question 10

Palpation of Skin

Answer 10

temperature
moisture
texture
thickness
edema
turgor
hair
nails

Question 11

Primary skin lesions

Answer 11

arise from healthy skin tissue

macule, papule, nodule/tumor, vesicle, pustule, wheal

Question 12

Secondary skin lesions

Answer 12

result from change in primary or injury

scale, ulcer

Question 13

Macules/Patches

Answer 13

flat to the skin
circumscribed
change in skin color 
< 1 cm - macules
> 1 cm - patches
ex: freckles, Mongolian spots

Question 14

Petechiae

Answer 14

leakage of blood into skin
smooth
nonblanchable
red, small, seen if person is on anti-coagulant and capillaries are releasing blood

Question 15

Purpura

Answer 15

leakage of blood into skin
smooth
nonblanchable
range from red to purple, larger, bigger than petechiae (seen in vascular diseases)

Question 16

Ecchymosis

Answer 16

leakage of blood into skin due to trauma/injury
smooth
nonblanchable
bruise

Question 17

Papules

Answer 17

raised, palpable lesions
< 1 cm 
circumscribed
solid elevation
ex: moles, warts

Question 18

Nodules

Answer 18

1-2 cm
circumscribed
deeper
ex: lipoma

Question 19

Vesicles and Bullae

Answer 19

vesicles < 1 cm 
bullae > 1 cm
circumscribed
fluid-filled
Ex: blister

Question 20

Pustules

Answer 20

vary in size
usually yellow-white in color
purulent filled
ex: acne, folliculitis

Question 21

Plaques

Answer 21

> 1 cm
plateau-like elevation
scaly texture
ex: psoriasis

Question 22

Wheals

Answer 22

vary in size
irregularly shaped
superficial
ex: hives

Question 23

Patterns of lesions

Answer 23

discrete
diffuse
confluent

Question 24

Pressure ulcers

Answer 24

area of skin breakdown that occurs secondary to constant pressure to one area
blood supply, oxygen and circulation reduced to area

Question 25

Pressure ulcer assessment factors

Answer 25

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”

Question 26

Pressure Ulcer Stage 1

Answer 26

skin appears red but unbroken

localized redness doesn’t blanch

Question 27

Pressure Ulcer Stage 2

Answer 27

partial-thickness skin erosion
loss of epidermis and/or dermis
ulcer looks shallow like abrasion or open blister

Question 28

Pressure Ulcer Stage 3

Answer 28

full-thickness
extends into subcutaneous layer looking like a crater
peri-wound involvement

Question 29

Pressure Ulcer Stage 4

Answer 29

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

Question 30

Unstageable Pressure Ulcer

Answer 30

necrotic tissue or slough is covering base of the ulcer

Question 31

Skin Cancer Assessment

Answer 31

Asymmetrical shape
Border irregular
Changes in color
Diameter > 6 mm
Evolving, elevation

Question 32

Cause of pressure ulcers

Answer 32

pressure
friction
shear
moisture

Question 33

Intrinsic pressure ulcer factors

Answer 33

things that the patient comes in with
age
disease
immobility
sensory loss
body type
poor nutrition
infection
incontinence

Question 34

Extrinsic pressure ulcer factors

Answer 34

things that we do as healthcare providers
incontinence 
excessive uniaxial pressure
friction and shear force
impact injury
heat
moisture 
posture

Question 35

Braden scale

Answer 35

method of assessing the risk of pressure ulcers
sensory perception
moisture
activity
mobility
nutrition
friction and shear
lower total score = higher risk

Question 36

Braden scale scores

Answer 36

general trigger for potential pressure ulcer risk problem (max score 23)
below 16 is at risk
below 12 is high risk

Question 37

Supine position ulcer areas

Answer 37

skull
shoulder/scapula
heel
elbow

Question 38

Side-lying position ulcer areas

Answer 38

groin
feet
knee
hip
elbow
wrist

Question 39

Prone position ulcer areas

Answer 39

ear
breast
toe
knee
wrist

Question 40

Wheelchair position ulcer areas

Answer 40

buttock
heel
knee
shoulder/scapula 
back

Question 41

Fowler’s position ulcer areas

Answer 41

heel
toe
wrist
elbow
scapula/shoulder
head