skin and tissue integrity Flashcards
skin color is derived from what three sources
Melanin—brown pigment
Carotene—yellow-orange pigment
Red purple tones in the underlying vascular bed
all individuals have what difference with skin color
All individuals have varying amounts (red, yellow, and brown).
With the relative proportion affecting prevailing color
Also modified by thickness of skin and presence of edema
the skin is and has what
Skin is washable, waterproof, & rugged -> has protective & adaptive properties
the types of functions of skin
protection
prevents penetration
perception
fluid balance
temperature regulation
identification
communication
wound repair
absorption and excretion
production of vitamin D
medications - tetracycline
- given a lot for people with acne
- makes the skin more sensitive and prone to sunburns
subjective data health history questions
Past history of skin disease, allergies, hives, psoriasis, or eczema
Change in pigmentation
Change in mole (size or color)
Excessive dryness or moisture
Pruritus
Excessive bruising
Rash or lesions
Environmental or occupational hazards
inspect and palpate the skin - color
Color
General pigmentation, freckles, moles, birthmarks
Widespread color change
* Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow)
* Note if color change transient or due to pathology
inspect and palpate the skin - temperature
Use backs of hands to palpate person
Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status.
Hands and feet may be slightly cooler in a cool environment.
* Hypothermia
* Hyperthermia
inspect and palpate the skin - what to check for in moisture
diaphoresis
dehydration
inspect and palpate the skin - lesions
if any are present, note the following:
Color
Elevation flat, raised or pedunculated
Pattern or shape grouping or distinctness
Size measure in centimeters
Location and distribution on body
Any exudate: note color and odor
Use a dermatoscope for closer inspection
ABCDEF skin assessment (exam)
- A: asymmetry
- B: border irregularity
- C: color variations
- D: diameter greater than 6 mm
- E: elevation or evolution
- F: funny looking—“ugly duckling” —different from others
what should you do for the ABCDEF skin assessment
Promoting health and self-care
Teach skin self-examination using ABCDEF rule to detect suspicious lesions
developmental competence: infant skin presentations
Skin color—general pigmentation
Mongolian spot
Café-au-lait spot
Skin color change
Harlequin color change
Erythema toxicum
Temporary cyanotic conditions
Acrocyanosis
Cutis marmorata
Physiologic jaundice
Carotenemia
Moisture, texture, thickness, mobility and turgor
Vascularity or bruising—nevus simplex
Hair and nails—lanugo and presence of cyanosis in newborn
developmental competence: life-cycle presentations - adolescents
Adolescent
Acne
Open and closed comedones
developmental competence: life-cycle presentations - pregnancy
Striae (stretch marks)
Linea nigra
Chloasma
Vascular spiders
developmental competence: life-cycle presentations - aging for skin color and presentations (exam)
- Solar lentigines (liver spots) -> dark spots, often from sun exposure
- Keratoses -> seborrheic or actinic
developmental competence: life-cycle presentations - aging for moisture (exam)
xerosis - dry skin
developmental competence: life-cycle presentations - aging for texture
- Skin tags or acrochordons
- Sebaceous hyperplasia
developmental competence: life-cycle presentations - aging for thickness
Thin parchment as subcutaneous fat decreases
developmental competence: life-cycle presentations - miscellaneous
Decreased mobility and turgor
Decreased hair growth, nail growth, and brittle nails
define xerosis
known as dry skin
- excessive dry skin
detecting color changes in light and dark skin
Be aware of normal variations for the following variables:
Pallor
Cyanosis
Erythema -> redness and swelling of the skin
Jaundice -> often shows liver damage
common shapes and configurations - annular or circular
begins in the center and spreads to periphery
common shapes and configurations - confluent
lesions run together
common shapes and configurations - discrete
distinct and separate
common shapes and configurations - grouped
cluster of lesions
common shapes and configurations - gyrate
twisted, coiled, or snakelike
common shapes and configurations - target or iris
resembles iris of the eyes, concentric rings
common shapes and configurations - linear
scratch, streak, line, or stripe
common shapes and configurations - polycyclic
annular lesions grow together
common shapes and configurations - zosteriform
linear arrangement following a unilateral nerve route
primary skin lesions - macule (exam)
Solely a color change, flat and circumscribed, less than 1 cm
- will not feel it
primary skin lesions - papule
Felt and caused by superficial thickening of the epidermis
primary skin lesions - patch
Macules that are larger than 1 cm
primary skin lesions - plaque
Papules coalescing to form surface elevation wider than 1 cm
primary skin lesions - nodule
Solid, elevated, hard or soft, greater than 1 cm that may extend deeper into dermis than papule
primary skin lesions - wheal
Superficial, raised, transient and erythematous, irregular in shape due to edema
- multiple clustered together is hives
primary skin lesions - tumor
Larger in diameter, firm or soft, deeper into dermis, may be benign or malignant
primary skin lesions - urticaria (hives)
Wheals coalesce to form extensive pruritic reaction.
primary skin lesions - vesicle
Elevated cavity containing fluid up to 1 cm (blister)
primary skin lesions - cyst
Encapsulated fluid filled cavity
primary skin lesions - bulla
Larger than 1 cm diameter, usually single chamber, superficial in dermis and ruptures easily
primary skin lesions - pustule
Pus in cavity that is circumscribed and elevated.
secondary skin lesions - debris of skin surfaces
Crust—Thickened dried out exudate
Scale—Compact flakes of desiccated skin from shedding of dead excess keratin cells
secondary skin lesions - break in continuity of skin surfaces
Fissure—Linear crack with abrupt edges extending into dermis
Erosion—Scooped out but shallow depression
Ulcer—Deeper depression extending into dermis with irregular shape, may bleed, leaves scar
Excoriation—Self-inflicted abrasion that is superficial
Scar—Permanent fibrotic change after healing
Atrophic scar—Resulting skin level is depressed with loss of tissue and thinning
Lichenification—Prolonged intense scratching leads to thickened skin producing tightly packed set of papules
Keloid—Benign excess of scar tissue beyond original injury
stages of pressure injuries (exam)
Stage I: Non-blanchable erythema
Stage II: Partial-thickness skin loss
Stage III: Full-thickness skin loss
Stage IV: Full-thickness skin/tissue loss
DTPI
deep tissue pressure injury
- can be caused by medical devices
hemangiomas
Port-wine stain (nevus flammeus)
Strawberry mark (infantile hemangioma)
Deep hemangioma (mature)
telangiectases
Spider angioma
Venous lake
pupuric lesions
Petechiae
Ecchymosis
Purpura
lesions caused by trauma or abuse
Mechanical injury
Contusion (bruise)
common skin lesions in children
Diaper dermatitis
Candidiasis
Impetigo
Atopic dermatitis (eczema)
Measles (rubeola)
German measles (rubella)
Chickenpox (varicella)
common skin lesions in general
Primary contact dermatitis
Allergic drug reaction
Tinea corporis (ringworm of the body)
Tinea pedis (ringworm of the foot)—Athlete’s foot
Labial herpes simplex (cold sores)
Tinea versicolor
Herpes zoster (shingles)
Erythema migrans of Lyme disease
Psoriasis
types of malignant skin lesions
Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
