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Skin Integrity Assessment > Skin Assessment > Flashcards

Skin Assessment Flashcards

0
Q

Stratum Corneum

A

Contains dried keratinocytes for protection, permeability barrier
Disease of this layer includes tinea versicolor, a fungal infection

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1
Q

The Skin

A
  • Reflects inner health
  • Barrier, protects and prevents penetration
  • perception, sensation
  • thermoregulation
  • absorbs and excretes
  • identification
  • communication
  • synthesized vit D
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2
Q

Epidermis

A
  • 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
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3
Q

Keratinocytes

A

Non-hyperproliferative disease (ichtyosis vulgaris)
Benign hyperproliferative diseases (psoriasis, actinic keratosis)
Malignant diseases ( basal cell CA, squamous cell CA)

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4
Q

Melanocytes

A

Diseases include albinism (reduces melanocytes) and Addison’s Disease (increased pigmentation)

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5
Q

Langerhan’s cells

A

Disease includes contact eczematous dermatitis

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6
Q

Merkel Cells

A

Slowly adapting mechanoreceptors

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7
Q

Basement Membrane Zone

A

Diseases include bullous penphigoid, herpes gestationes, and systemic lupus erythematosus

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8
Q

Dermis

A
  • 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
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9
Q

Appendages

A

Hair
Sebaceous glands
Sweat glands
Nails

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10
Q

RBC lives

A

120days

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11
Q

WBC lives

A

18-24hrs

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12
Q

Subcutaneous layer

A
  • comprised of lobules of fat cells
  • provides insulation
  • aids in protection
  • provides upper layers with increased mobility
  • contains carotene
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13
Q

Carotenes

A

Typical yellow-colored fat is a result of fat storage of these in their diet

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14
Q

Aging Factors:EPIDERMIS

A 
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
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15
Q

Aging Factors: DERMIS

A 
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
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16
Q

Aging Factors:SUBCUTANEOUS

A 
Cellulite 
Bags over/under eyes 
Double chin
Abdominal fat increase 
Saggy breast 
Tenting when pinched (turgor tests)
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17
Q

Aging Factors:GLANDS

A

Decrease in eccrine and apocrine
Dry skin
Absent perspiration

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18
Q

Assessment

A 
Look
Palpate
Smell
Ask questions 
Labs (albumin)
Braden scale
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19
Q

Braden Scale

A 
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

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20
Q

Assessment of Wounds or Ulcers

A 
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)
21
Q

Tissue Integrity Alterations

A 
Corticosteroids 
(Thins skin/easily harmed)
Antibiotics
Chemo drugs
Psychotherapeutic drugs 
Impairs sun light sensitivity
22
Q

Pruitis

A

Itching associated with dry, scaly skin

May be symptoms of live or mite infestation

23
Q

Erythema

A

Redness accompanying inflammation

24
Q

Infectious: Bacterial

A

Boils, impetigo, infected hair follicles

25
Q

Infectious: fungal

A

Ringworm, athletes foot, jock itch, nail infection

26
Q

Viral

A 
Cold sores
Fever blisters (herpes simplex)
Chickenpox
Warts
Shingles (herpes zoster)
Measles (rubeola)
German measles (rubella)
27
Q

Parasitic

A

Ticks
Mites
Lice

28
Q

Inflammatory

A 
Overactive glands 
Increased hormones
Infection 
Acne
Rosacea
Itching 
Cracking 
Discomfort 
Eczema 
Dermatitis 
Psoriasis 
Sunburn
Environmental stresses
29
Q

Neoplastic

A

Malignant melanoma
Basal cell carcinoma
Squamous cell carcinoma

30
Q

ABCD

A

Asymmetry
Border
Color
Diameter

31
Q

Macule

A

Freckles
Flat, non-palpable
Color change only, <1cm

32
Q

Patch

A

Macules >1cm

33
Q

Papules

A

Palpable
Solid
Raised
<1cm diameter

34
Q

Plaque

A

Aggregations of papules/pustules that can be unroofed to leave denuded epithelium

35
Q

Coalesced papules

A

Plateau-like >1cm

36
Q

Nodule

A

Solid
Elevated
>1cm

37
Q

Tumor

A

Larger

> few cm

38
Q

Wheal

A

Superficial, raised, transient, irregular shape

39
Q

Urticaria

A

Coalesced wheals

Hives

40
Q

Psoriasis

A

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

41
Q

Primary skin lesions

A

Vesicle
Bulla
Pustule
Cyst

42
Q

Secondary skin lesions

A 
Crust
Scale 
Fissure 
Erosion 
Ulcer
Excoriation 
Scar
Atrophic scar
Lichenification
Keloid
43
Q

Vascular lesions

A 
Port wine stain
Strawberry Mark 
Cavernous hemangioma 
Spider or star angioma
Venous lake
Petechiae (DIC)
Purpura (DIC)
44
Q

Lesion Assessment

A

ID anatomic location and distribution
Note grouping or arrangement
ID type
Note Color

45
Q

Common Lesion Shapes

A 
Annular or circular 
Confluent
Discrete
Grouped 
Gyrate
Target
Linear
Polycyclic 
Zosteriform
46
Q

Crust of impetigo

A

Secondary to chicken pox

47
Q

Contact Dermititis

A

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

48
Q

Allergic Contact Dermatitis

A

Erythema, swelling, pruritic vesicles
Rupture, ooze, crust
Rash limited to area of contact

49
Q

Irritant contact dermatitis

A

Redness, edema, vesiculation, dryness of skin, scaling, fissures, and necrosis
Patch testing

50
Q

Nursing Process

A 
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

Skin Integrity Assessment (1 decks)

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