Skin Assessment Flashcards
Stratum Corneum
Contains dried keratinocytes for protection, permeability barrier
Disease of this layer includes tinea versicolor, a fungal infection
The Skin
- Reflects inner health
- Barrier, protects and prevents penetration
- perception, sensation
- thermoregulation
- absorbs and excretes
- identification
- communication
- synthesized vit D
Epidermis
- Cells in progression are as follows:
- Basal to spinous to granular layers with keratinocytes, melanocytes, langerhan’s cell and Merkel cell
- Diseases include psoriasis, exfoliative dermatitis, ichtyosis vulgaris, and keratosis follicularis
- outermost part of skin
- avascular
- epithelial cells
- 4-5 layers, palms and soles have additional layers
Keratinocytes
Non-hyperproliferative disease (ichtyosis vulgaris)
Benign hyperproliferative diseases (psoriasis, actinic keratosis)
Malignant diseases ( basal cell CA, squamous cell CA)
Melanocytes
Diseases include albinism (reduces melanocytes) and Addison’s Disease (increased pigmentation)
Langerhan’s cells
Disease includes contact eczematous dermatitis
Merkel Cells
Slowly adapting mechanoreceptors
Basement Membrane Zone
Diseases include bullous penphigoid, herpes gestationes, and systemic lupus erythematosus
Dermis
- Loose connective tissue with collagen, elastin, reticulin; cells are fibroblasts, macrophages, mast cells, lymphocytes.
- Structures include blood vessels, lymphatic vessels, nerves, sweat glands, apocrine, and sebaceous glands (lipid secretions)
- Diseases include scleroderma and urticaria
- supportive layer
Appendages
Hair
Sebaceous glands
Sweat glands
Nails
RBC lives
120days
WBC lives
18-24hrs
Subcutaneous layer
- comprised of lobules of fat cells
- provides insulation
- aids in protection
- provides upper layers with increased mobility
- contains carotene
Carotenes
Typical yellow-colored fat is a result of fat storage of these in their diet
Aging Factors:EPIDERMIS
decreases thickness -more fragile -delayed wound healing -hyperkeratoses and skin cancers Increased permeability (decreased langerhan's cells) -increased reaction -decreased inflammatory response Hyperplasia of melanocytes -liver spots -age spots Decreased vit D Risk of osteoporosis and osteomalacia Increased skin tears, purpura, and pressure ulcers
Aging Factors: DERMIS
Decreased perfusion -increase in dry skin Decreased sensation -risk of injury Decreased vasomotor response Risk of hypothermia/hyperthermia Elastic fiber degeneration Wrinkles Proliferation of capillaries Cherry hemangiomas
Aging Factors:SUBCUTANEOUS
Cellulite Bags over/under eyes Double chin Abdominal fat increase Saggy breast Tenting when pinched (turgor tests)
Aging Factors:GLANDS
Decrease in eccrine and apocrine
Dry skin
Absent perspiration
Assessment
Look Palpate Smell Ask questions Labs (albumin) Braden scale
Braden Scale
Sensory perception Moisture Activity Mobility Nutrition Friction/shear
Mild risk:15-18
Moderate risk:13-14
High risk:10-12
Very high risk:9 or below
Implement PUP for Braden of 18 or less
Assessment of Wounds or Ulcers
Acute wound or chronic wound Location Size (length, width, depth) Color Cleanliness Odor Presence of wound drains Presence of drainage and exudate (Serous, serosanguineous, sanguineous, purulent) Staging (1-4)
Tissue Integrity Alterations
Corticosteroids (Thins skin/easily harmed) Antibiotics Chemo drugs Psychotherapeutic drugs Impairs sun light sensitivity
Pruitis
Itching associated with dry, scaly skin
May be symptoms of live or mite infestation
Erythema
Redness accompanying inflammation
Infectious: Bacterial
Boils, impetigo, infected hair follicles
Infectious: fungal
Ringworm, athletes foot, jock itch, nail infection
Viral
Cold sores Fever blisters (herpes simplex) Chickenpox Warts Shingles (herpes zoster) Measles (rubeola) German measles (rubella)
Parasitic
Ticks
Mites
Lice
Inflammatory
Overactive glands Increased hormones Infection Acne Rosacea Itching Cracking Discomfort Eczema Dermatitis Psoriasis Sunburn Environmental stresses
Neoplastic
Malignant melanoma
Basal cell carcinoma
Squamous cell carcinoma
ABCD
Asymmetry
Border
Color
Diameter
Macule
Freckles
Flat, non-palpable
Color change only, <1cm
Patch
Macules >1cm
Papules
Palpable
Solid
Raised
<1cm diameter
Plaque
Aggregations of papules/pustules that can be unroofed to leave denuded epithelium
Coalesced papules
Plateau-like >1cm
Nodule
Solid
Elevated
>1cm
Tumor
Larger
> few cm
Wheal
Superficial, raised, transient, irregular shape
Urticaria
Coalesced wheals
Hives
Psoriasis
Skin cells that multiply up to 10x faster than normal
Cycles of remission and flare ups over time
No cure
Skin cells reach skin surface and die causing raised, red plaque covered with white scale
Primary skin lesions
Vesicle
Bulla
Pustule
Cyst
Secondary skin lesions
Crust Scale Fissure Erosion Ulcer Excoriation Scar Atrophic scar Lichenification Keloid
Vascular lesions
Port wine stain Strawberry Mark Cavernous hemangioma Spider or star angioma Venous lake Petechiae (DIC) Purpura (DIC)
Lesion Assessment
ID anatomic location and distribution
Note grouping or arrangement
ID type
Note Color
Common Lesion Shapes
Annular or circular Confluent Discrete Grouped Gyrate Target Linear Polycyclic Zosteriform
Crust of impetigo
Secondary to chicken pox
Contact Dermititis
Inflammation of skin that occurs in response to direct contact with allergen or irritant
-dyes, perfumes, poison plants, chemicals, metals, latex
Hypersensitivity
Irritant contact dermatitis
-inflammation from irritants
Soaps, chemicals, detergents
Allergic Contact Dermatitis
Erythema, swelling, pruritic vesicles
Rupture, ooze, crust
Rash limited to area of contact
Irritant contact dermatitis
Redness, edema, vesiculation, dryness of skin, scaling, fissures, and necrosis
Patch testing
Nursing Process
A-health assessment interview (chief complaint) examination D-impaired skin integrity Knowledge deficient P- Triggers identified and eliminated Free of infection I- medications to relieve symptoms Symptoms of infection Change environment or diet Barrier between allergen and skin Topical corticosteroids Reduce dry skin and relieve pruritus E-control dermatitis Triggers identified and eliminated Sleep minimally disturbed by itching
