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Assessment Test 2 > Skin Assessment > Flashcards

Skin Assessment Flashcards

1
Q

The skin is …. and …..

A

largest organ and the first line of defense

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2
Q

Nursing Problems with Skin

A

Infection, Fluid & electrolyte imbalance, Nutritional deficits, Tissue alterations

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3
Q

anatomy and physiology of the skin

A

epidermis - protection from injury; dermis; subcutaneous tissue

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4
Q

functions of skin

A

Protection; Heat regulation; Sensory perception; Excretion; Vitamin D production (get from sunlight)

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5
Q

respiratory system with skin

A

important to give oxygen to the tissues (cyanosis)

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6
Q

cyanosis

A

(central and peripheral cyanosis) inside mucus membranes of the mouth, nails - clubbing, hand peripheral - lack of blood flow to extremity, becomes very cold

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7
Q

angle of nail bed greater than 180

A

patients with COPD (cyanosis)

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8
Q

what other body systems work with skin

A

Respiratory System; Cardiovascular System; Gastrointestinal System; Urinary System; Neurological system; Endocrine System; Lymphatic/ Immune System

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9
Q

GI system

A

related to decreased ability to excrete toxins; mainly liver; in dark skin pts look at teh sclera of the eye to asses jaundice

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10
Q

cardiovascular

A

altered perfusion - lack of blood supply to the extremities; venus ulcer - occurs because of lack of blood flow to that area

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11
Q

urinary system

A

related to decrease ability to excrete toxins; edema - the pressure either not enough or too high (+4 deep, most common - lower extremities)

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12
Q

neurological system

A

Changes related to autonomic nervous system, changes in :Touch, temperature, pressure, pain; ANS controls the skin’s blood vessels and glades results in changes in moisture and temperature; (loss of sensation because of sensory receptors in the skin)

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13
Q

Endocrine system

A

Diabetes-ulcerations of the foot; Hypo or hyperthyroidism (dryness or increased moisture) hair becomes brittle and sparse (so oily hair and moist skin); Adrenal disease - adrenal glands - tie in w/ meds, drier skin, thinner hair, increases chance of bruising

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14
Q

Skin is a protective barrier, therefore,

A

the more breaks in the skin = increase risk of infection. Think about the number of access sites patients usually has. (immune system)

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15
Q

immune system

A

allergic reaction; psoriasis - over production of skin cells, really dry; dermitis - usually w/ catheters, red painful; lupus erythematosus - butterfly rash

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16
Q

health history

A

Changes in skin, hair, nails; Mole/lesion, pruritus, rashes; Allergies; Medical condition (diabetes, thyroid, liver, heart); Exposure to infectious/contagious illness; Medications; Family history; Psychosocial profile; Review of Systems

17
Q

physical assessment

A

Color; Temperature (check both sides); Moisture; Turgor- skin elasticity (how well pt is hydrated); Texture; Odor; Hair; Nails—clubbing, infections (pressure to nail then return pink less than 3 seconds)

18
Q

abnormal findings

A

lesions and pressure ulcers

19
Q

lesions

A

Circumscribed areas of pathologically altered tissue; Described by Patterns & Configuration (Discrete, Confluent, Circular, Linear); Described by Distribution (Diffuse, Scattered, Localized, Regional,Dermatone); Described by Size, Shape, Elevation, Depression

20
Q

types of lesions

A

Macule; Papule; Vesicle; Wheal/Hive; Bulla; Pustule; Nodule/Tumor

21
Q

macule

A

flat, circumscribed, discolored, less than 1 cm in diameter ex. freckles, tattoos, storkbite

22
Q

papule

A

raised, defined, any color, less 1 cm in diameter ex. wart, insect bite, mulluscum, contaisum

23
Q

vesicle

A

fluid filled, less than 1 cm diameter, ex. herpes simplex, chicken pox

24
Q

warning signs

A

A—asymmetry; B—border irregularity; C—color variation; D—diameter > 6mm; E—elevation (controversial)

25
Q

risk factors of pressure ulcers

A

Impaired mental status; Impaired nutritional status; Sensory Deficits; Immobility; Mechanical Force; Shearing and Friction; Increased Temperature; Excessive exposure to moisture

26
Q

diagnosis

A

diagnosis - impaired skin integrity, at risk for infection; outcomes - very specific; interventions - actions taken

27
Q

wheal/hive

A

raise flesh, colored or red edentous papules or plaques, vary in size/shape, ex. urticaria

28
Q

bulla

A

fluid filled greater than 1 cm in diameter, ex. second degree burn, bullous impetigo

29
Q

postule

A

purulent, fluid filled, raise of any size, ex. acne, folliculitis

30
Q

nodule

A

solid palpable greater than 1 cm in diameter, often with depth, ex basal cell carcinoma

31
Q

tumor

A

large nodule, ex large nerves, basal bell carcinoma, lipoma

Assessment Test 2 (8 decks)

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