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Nursing - 115 > Skin Assessment - Unit 2 > Flashcards

Skin Assessment - Unit 2 Flashcards

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1
Q

What is some of the subjective data for health history questions?

A

Previous history of skin disease, change in pigmentation, change in mole (size or color), excessive dryness or moisture, excessive bruising, itching, hair loss, self care behaviors, etc.

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2
Q

Pruritus - def

A

Itching.

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3
Q

Objective Data - what do we look for?

A

Color (general pigmentation, widespread color change), temp, moisture, texture.

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4
Q

Skin Color - assess areas ___ exposed to sun and assess for ___ pigmentation.

A

NOT exposes/even pigmentation.

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5
Q

What is skin color influenced by?

A

Amount of melanin, oxygen content in blood, level of exposure to sun, etc.

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6
Q

Dark skin - large or little amounts of melanin?

A

Large amounts!

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7
Q

Light skin - large or little amounts of melanin?

A

Little!

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8
Q

Asian skin - large amount of carotene. T/F?

A

True!

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9
Q

What are some of the variations of the skin color/tone?

A

Pinkish tan to ruddy dark tan, light to dark brown, may have yellow or olive overtones, pink, tan, brown or black.

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10
Q

Dark skin people - normally have areas of lighter pigmentation on palms, nail beds & lips. T/F?

A

True!

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11
Q

Where are some good areas to asses changes in coloration for darker skinned people?

A

Under the tongue, buccal mucosa (cheek), conjunctivae (eyelids), sclera (white part of eyes)

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12
Q

Cyanosis - def

A

mottled blue color in skin.

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13
Q

Cyanosis - increased amount of ____ ___ causing inadequate tissue perfusion.

A

Unoxygenated hemoglobin.

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14
Q

Cyanosis - what color?

A

Blueish color!

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15
Q

Pallor - def and what causes it?

A

loss of color because there is an absence of oxygenated Hbg.

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16
Q

Light skin - pallor - lose __ tone.

A

Rosy

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17
Q

Pallor - skin with natural yellow tone becomes more…

A

Yellow, which is why it can be mistaken for jaundice.

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18
Q

Dark skin - pallor - loses healthy ___.

A

Glow.

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19
Q

Pallor - black skin - loses __ undertones and appears __ __ and ___.

A

Red/ash grey and dull.

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20
Q

Pallor - brown skin - appears ___ ____ and ___.

A

Yellow brown/dull.

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21
Q

Jaundice - yellow undertone caused by increased ___ in blood.

A

Bilirubin

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22
Q

Erythema (redness) - what is it?

A

Light skin = red, bright pink and with dark, it’s a purplish tint.

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23
Q

What is the normal temp of skin?

A

Warm.

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24
Q

Skin temp - varies depending on circulation and limbs? T/F?

A

True!

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25
Q

Skin moisture - usually __ with moisture in axilla, skin folds and in response to activity or anxiety/emotional state.

A

Dry!

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26
Q

Turgor (elasticity) - indicator of total body ___.

A

Hydration.

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27
Q

Turgor - “Tenting” test (Pinch-fold test) - use forehead for the test. T/F?

A

True!

28
Q

Edema - def

A

fluid that accumulates in intercellular spaces - excess fluid not normally present.

29
Q

Edema - looks ___ and __.

A

Puffy and tight.

30
Q

Edema - assess ___, whether area remains _____ (or pitted), when press with finger.

A

Location/indented.

31
Q

Scale for Describing Edema - 1+ 2+ 3+ 4+

A

1+ - Barely detectable, slight indentation (2mm) 2+ - Indentation of less than 5mm 3+ - Indentation of 5-10mm w/puffy, deeper pitting. 4+ - Indentation of more than 10mm - extremely deep pitting.

32
Q

With edema, ask if it’s normal for the patient. T/F?

A

True!

33
Q

Skin texture - smooth, soft and more coarse with aging. T/F?

A

True!

34
Q

Thyroid problems can can skin dryness, and hyperthyroidism can cause velvet smooth skin. T/F?

A

True!

35
Q

Lesions of skin - def

A

pathologic change in structure of the skin.

36
Q

Assessment of lesions - what do we look for?

A

Color, elevation (flat or raised?), pattern or shape, border, size (in CM), location and distribution, and exudate (fluid = COCA - Color, Odor, Consistency, Amount)

37
Q

What are these? (top left to bottom right.)

A

Annular, Confluent, Discrete, grouped, gyrate, target, linear, polycyclic, zosteriform.

38
Q

What are these? (Top left to bottom right)

A

Sharp, Ill-defined, Circinate, Arciform, Annular, Iris, Serpiginous, Gyrate, Linear, Zosteriform

39
Q

What are these distributions? (top left to bottom right.)

A

Localized, Generalized, Symmetric, Assymetric (Shingles?), Discrete, Grouped, Coalescing (Smaller and bigger lesions together), Clevage Plane

40
Q

Primary Lesion - def

A

lesion that is a physical alteration of the skin and considered to be directly caused by the diease process which is characteristic and ocassionally specific. This could be a tumor or a papule, etc.

41
Q

Secondary Lesion - def

A

lesion that changes of time or as a result of scratching, trauma, infection or changes caused by healing. Examples could be Scale, Crust, Erosion, etc.

42
Q

Flat primary lesions - def

A

circumscribed, flat non-palpable changes in skin color - they are well defined and have definite boundaries or limits. (Think about a birth mark!)

43
Q

Macule - def

A

flat, discolored lesion with no elevation - <1 CM in size.

44
Q

Patch - def

A

flat, nonpalpable, irregular - >1CM in size.

45
Q

Vitiligo - def (this is a patch!)

A

autoimmune disorder - destruction of melanocytes (melanin producing cells). It looks like a dark person has been bleached!

46
Q

Raised Primary Lesions - def

A

palpable, elevated solid masses.

47
Q

Types of Raised Primary Lesions (info on them!)

Papule

Plaque

Nodule

Tumor

Wheal

A

Papule - elevated pinpoint lesion, < than 1 CM. Solid, raised.

Plaque - groupes of papules, >1 CM and do not extend into lower skin layers. Can be silvery!

Nodule - elevated, solid, hard or soft, palpable masss extending deeper into dermis than a papule - 1-2CM in diamter. Could be a swollen lymph node!

Tumor - >2 CM in diameter - solid mass larger than a nodule.

Wheal - elevated transient with a variable diameter; superficial localized skin edema.

48
Q

Tumor does mean neoplasm. T/F?

A

False - tumor doesn’t mean neoplasm. Neoplasm = cancerous.

49
Q

Fluid filled primary lesions - def

A

circumscribed, superficial elevations of the skin formed by free fluid in a cavity within the skin layers.

50
Q

Types of Primary Lesions w/fluid. (info!)

Vesicle, Bulla, Pustule, Cyst

A

Vesicle - fluid filled papule <1CM. Think chickenpox!

Bulla - >1CM, fluid filled - larger than a vesicle. Large fluid filled blisters!

Pustule - elevated, pus filled vesicle or bulla.

Cyst - encapsulated, may or may not be elevated - fluid filled or semi solid mass.

51
Q

What are these primary lesions? (Top left to bottom right.)

A

Macule, papule, plaque, vescicle, bulla, pustule, wheal, nodule/tumor.

52
Q
A
53
Q
A
54
Q

Secondary lesions - Type - info

Scales, Crusts, Excoriation, Fissures

A

Scales - flakes of dead epidermis - epidermal thickening.

Crusts - covering formed from serum, blood or pus drying on the skin - dried serum.

Excoriation - injury to surface of skin causd by trauma such as scratching or abrasion - linear loss of epidermis (erosion pertains to loss of epidermis, not linear.)

Fissures - linear cracks with sharp edges extending into dermis - a crack or slip!!!

55
Q
A
56
Q

Kawasake’s Disease - serious viral infection. T/F? It also affects the heart.

A

True!

57
Q

More secondary lesions -

Ulcers, Scar, Atrophy, Striae, Lichenification

A

Ulcers - lesion formed by loss of epidermic and extending into deeper tissues. Loss of epidermis and dermis!

Scar - area of connective tissue left after lesion or wound is healed - it is a thickening, fibrous tissue.

Atrophy - translucent, dry, paper like, sometimes wrinkled skin surface as result of thinning or wasting of skin due to loss of collagen and elastin - loss of substance/thinning.

Striae - long line, appearing like scars related to stretching of subcutaneous skin.

Lichenification - thickening with skin line accentuation.

58
Q

Keloid - a type of scar. T/F?

A

Yes, it’s excess scar tissue and icnreased cartilage pudction. Reddish, darkened, etc. It can happen with a piercing!

59
Q

What are these secondary lesions? (Top left to bottom right)

A

Scale, crust, fissure, erosion, ulcer, lichenification, epidermal atrophy, dermal atrophy.

60
Q

Vascular Skin Lesions - def

A

lesions pertaining to blood vessels

61
Q

Vascular Skin Lesions- info

Ecchymosis

Hemangioma

Hematoma

Petechiae

Purpura

A

Ecchymosis - accumulation of extravascular blood in dermis or subcutaneous tissue.

Hemangioma - cherry red, raised lesions that blanch with pressure.

Hematoma - localized, deep collection of blood beneath subcutaneous tissue.

Petechiae - hemmorhagic pinpoint spots.

Purpura - flat, irregularly shaped extensive patches of varying size.

62
Q

Ecchymosis - red, large patch, irregular edge, changing colors. T/F?

A

True!

63
Q

Petechiae - info

A

small lesions, could be liver disease, septicemia, clotting disorder. It’s a minor hemmorhage.

64
Q

Purpura - info

A

inflammation of blood vessels caused by disease or severe allergic reactions. These are purple dots.

65
Q

Purpura and Petechiae - these do blahce. T/F?

A

FALSE- they do not!

66
Q

Senile purpura - what is it?

Steroid Purpura - what is it?

A

Senile - in older people, probably not on clotting meds.

Steroid - decreasing tissue mass from steroids - muscle mass wasted away.

67
Q
A

Nursing - 115 (35 decks)

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