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Nurse Assessment > Skin, hair, nails > Flashcards

Skin, hair, nails Flashcards

1
Q

What is the importance of a skin assessment?

A

The skin is the largest organ
It is the first line of defense, and guards against trauma, pathogens, etc.

So when the patient’s skin integrity is broken the patient is at risk of infection and illness. We want to prevent this.

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2
Q

What are some functions of the skin?

A

Immune system function
Synthesis of vitamin D
Thermoregulation
wound repair

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3
Q

What are the layers of the skin?

A
  1. Epidermis- outer rugged protective layer
  2. Dermis- inner supportive layer
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4
Q

What does the epidermis consist of?

A

Basal cell layer (stratum basale)

Horny Cell layer (stratum corneum)

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5
Q

What does the basal cell layer (stratum basale) consist of?

A

inner later; Melanocytes are produced here. They produce melanin, which gives skin its color.

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6
Q

What does the horny layer (stratum corneum) consist of?

A

outmost layer; This is the layer that has dead skin cells that shed every four weeks.

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7
Q

What does the dermis consist of?

A

connective tissue (collagen)
elastic tissue
nerves, sensory receptors, blood vessels & lymphatics

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8
Q

What layer are the epidermal appendages embedded in (hair follicles, sebaceous glands, sweat glands)?

A

the dermal layer.

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9
Q

What are eccrine glands?

A

sweat glands that are all over the skin.

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10
Q

What are apocrine glands?

A

produce viscous lipid-rich sweat. looks yellowish.

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11
Q

What is the subcutaneous layer?

A

Lies beneath the two layers of the skin
Made of adipose tissue
stores fat for energy
provides insulation
soft cushion aids in protection
loose layer gives skin mobility over structures underneath.

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12
Q

What are some characteristics of aging skin?

A

Drier, flatter skin
Decreased sebum (oil) and sweat production
Decreased elasticity
Decreased number of functioning melanocytes
Decreased elastin, collagen, subcutaneous fat
change in thermoregulation (decreased function of the hypothalamus)
change in nails

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13
Q

T/F: there is increased vascular fragility in older individuals.

A

TRUE. Veins in older patients are stagnant, and kind of stay in place. This is due to decreased vascular + skin elasticity

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14
Q

Who is most at risk from damage to pressure due to changes in circulation and decreased ability to form new collagen?

A

Older patient. This is why mepilex bandages are used quite frequently in the hospital for older patients.

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15
Q

What are some strategies nurses can implement to reduce injuries of skin for older adults?

A

-Try not to apply really adhesive tape, it can cause tears on their skin

-apply lotion as it decreases dryness.

-increase hydration

  • advise not to take a shower every day, or if they do, try to stay away from using soap and apply oxygen.
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16
Q

T/F: very thin and very obese patients are at higher risk for skin breakdown.

A

TRUE

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17
Q

What can cause pressure injury development?

A

External pressure
Friction and Shearing
immobility
nutrition and hydration
moisture
mental status
age

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18
Q

Define a stage I pressure injury.

A

Intact skin with nonblanchable erythema.

Meaning if you push down on the red skin, it does not change color upon pressure. Stays the same red color.

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19
Q

Define a stage II pressure injury.

A

partial thickness loss of the dermis. Presents as an abrasion or a blister.

Looks almost like a burn.

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20
Q

Define a stage III pressure injury.

A

Full-thickness skin loss and subcutaneous tissue may be visible and presents as a deep crater

Underlying muscle is visible and exposed to outside environment.

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21
Q

RYB wound classification.

A

The universal classification of wounds by color.

Red, yellow, black

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21
Q

Define a stage IV pressure injury.

A

Full-thickness skin loss. Tissue necrosis or damage to muscle, bone, or supporting structures.

Stage IV pressure injury must involve damage to muscle bone or supporting structures.

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21
Q

What would we do with a Yellow pressure wound?

A

Cleanse it. Get rid of the sluff (oozing, exudate, drainage).

cleaning needed. Irrigate it using a wet to moist dressing, nonadherent dressing, or topical antimicrobial medication.

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22
Q

What would we do with a black pressure wound?

A

We would debride (remove) it.

mechanical debridement- using a scalpel or scissors to cut away the dead tissue.

scrubbing wound or applying wet to moist/dry dressing
chemical debridement- using a collagenase enzyme or autolytic debridement to help body break down necrotic tissue.

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22
Q

What would we do with a Red pressure wound?

A

We would protect. Meaning prevent further damage.

gentle cleansing, use of moist dressings, application of a transparent dressing, change dressing when necessary.

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23
Q

Define pallor and where to look on darker skinned individuals

A

pale in color. Look at the sclera of the eyes and mouth.

24
Q

define erythema

A

Superficial reddening of the skin, usually in patches from injury or irritation.

25
Q

Define cyanosis

A

A bluish discoloration of the skin due to inadequate oxygenation of the blood. Can look at the Lips.

26
Q

Define jaundice

A

yellow/green discoloration of the skin due to liver/gallbladder issues. Can look at the sclera of eyes.

27
Q

What is the normal shape of the nails?

A

Convex shape, <160 degrees

28
Q

How do we assess capillary refill?

A

Apply pressure to the nail bed for 4 seconds and measure how fast the color returns. should restore color <1-2 seconds.

29
Q

When performing a skin self-examination, what is the ABCDEF rule for danger signs of lesions?

A

A-asymmetry
B- border irregularity
C-color variation
D-diameter (>6mm)
E-elevation and evolution
F-funny looing

30
Q

Define annular or circular shape of lesions.

A

Lesion is circular and spread out.

31
Q

Define grouped shape of lesions.

A

small lesions grouped together, local to a specific area.

32
Q

Define gyrate shape of lesions

A

Almost worm looking, squiggly lines local to a specific area.

33
Q

Define linear shape of lesions

A

a single line going parallel to a structure on the body. Common sight seen with shingles.

34
Q

Additional skin conditions to think critically about:

Petechiae

A

Tiny punctate hemorrhages, 1 to 3 mm, round and discrete. Color is dark, red, purple, or brown and color.

Caused by bleeding from superficial capillaries; will not blanch.

May indicate abnormal clotting factors.

In darker skinned people, it is best visualized in the areas of lighter melanization (e.g., abdomen, buttocks, and volar surface of the forearm).

Possible diseases: thrombocytopenia, subacute, bacterial, endocarditis, and other septicemias.

Inspect for petechiae in the mouth, particularly the vehicle mucosa, and in the conjunctivae.

Different than a bruise, because it is not caused by blunt force trauma

35
Q

Additional skin conditions to think critically about:

Purpura

A

Confluent and extensive patch of petechiae and ecchymoses (a purpleish patch, resulting from extravasation of blood into the skin). Larger than 3 mm, flat, red, purple, macular hemorrhage.

Seen in generalized disorder, such as thrombocytopenia, coagulation disorders, and scurvy. Also occurs an old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis.

Different than a bruise, because it is not caused by blunt force trauma

36
Q

Additional skin conditions to think critically about:

Hematoma

A

Localized pooling of extravasated blood, usually clotted in an organ, space, or tissue. A hematoma looks like a goose egg.

The pooling blood gives the skin a spongy, rubbery, lumpy feel. A hematoma usually is not a cause for concern. It is not the same thing as a blood clot in a vein, and it does not cause blood clots.

37
Q

Additional skin conditions to think critically about:

Ecchymosis

A

Lesions caused by trauma or abuse. (Pic of arm with different stages of bruising).

A hemorrhagic spot or blotch, larger than petechia, in the scanner, mucous membrane, forming a non-elevated, rounded, or irregular blue or purpleish patch.

Different than a bruise, because it is not caused by blunt force trauma (Note on pg. 237)?

38
Q

Additional skin conditions to think critically about:

Necrosis/eschar

A

Dead tissue. Black.

Eschar: dead tissue that eventually sluff off healthy skin after an injury.

39
Q

Additional skin conditions to think critically about:

Patterns

A

A patterned injury is one which has a distinct pattern that may reproduce the characteristics of the object causing the injury. The wound on your skin matches the size and shape of the object that your skin touched. For example, nail markings caused by cat scratch.

Often signs of abuse. (Pic of child with bite marks, cigarette burns, deformed arm from untreated break, etc).

40
Q

Add additional skin conditions to think critically about:

Striae

A

(Linea albicantes, or stretch marks).

Pigment change. Silvery white, linear, jagged marks about one to 6 cm long. They occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged, stretching, as in pregnancy or excessive gate, weight gain, stray, or pink or blue; then they turn silvery white.

41
Q

Skin Abnormality:

Nodule

A

Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule.

Example; xanthoma, fibroma, intradermal nevi

42
Q

Skin Abnormality:

Wheal

A

Superficial, raised, transient, and erythematous; slightly irregular shaped from edema (fluid, held diffusely in the tissues).

Example: mosquito bite, allergic reaction, dermatographism.

43
Q

Skin Abnormality:

Vesicle

A

Elevated cavity, containing free fluid, up to 1 cm; a “blister. “Clear serum flows if wall is ruptured.

Example: herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis.

44
Q

Skin Abnormality:

Cyst

A

Encapsulated fluid – filled cavity and dermis or subcutaneous layer, tensely, elevating skin.

Examples: sebaceous cyst, wen.

45
Q

Skin Abnormality:

Pustule

A

Turbid fluid (pus) in the cavity. Circumscribed and elevated.

Examples: impetigo, acne

46
Q

Skin Abnormality:

Crust

A

The thickened, dried – out, exudate left when vesicles/pustules burst or dry up. Color can be red – brown, honey, or yellow, depending on fluid ingredients (blood, serum, pus).

Examples: impetigo (dry, honey – colored), weeping eczematous, dermatitis, scab after abrasion.

47
Q

Skin Abnormality:

Scale

A

Compact, desiccated flakes of skin, dry, or greasy, silvery or white, from shedding of dead excess keratin cells.

Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver micalike), seborrheic dermatitis (yellow, greasy), eczema ichthyosis (large, adherent, laminated), dry skin.

48
Q

Skin Abnormality:

Fissure

A

Linear crack with abrupt edges; extends into dermis; dry, or moist.

Examples: cheilosis— at corners of mouth caused by excess moisture; athletes foot.

49
Q

Skin Abnormality:

Excoriation

A

Self – inflicted, abrasion; superficial; sometimes crested; scratches from intense itching.

Examples: insect bites, scabies, dermatitis, varicella.

50
Q

Skin Abnormality:

Keloid

A

A benign excess of scar tissue beyond sites of original injury: surgery, acne, ear, piercing, tattoos, infections, burns. Looks smooth, rubbery, shiny, and “claw like”; feel smooth and firm. Found an earlobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma. Most common ages are 10 to 30 years; higher incidents in black, Latino, and Asian people.

51
Q

Abnormal findings

Common skin lesions

A

-Primary contact dermatitis
-Allergic drug reaction
-Tinea corporis (ringworm of the body)
-Psoriasis
-Herpes simplex (cold sores)
-Herpes zoster (shingles)

52
Q

Abnormal findings

Malignant skin lesions and AIDS

A

-Basal cell carcinoma
-Squamous cell carcinoma
-Malignant melanoma
-oral Kaposi sarcoma

53
Q

Practice question

A patient who is admitted for for liver failure would be likely to show which of the following skin changes?

A. Cyanosis
B. Flushing
C. Rubor
D. Jaundice

A

D. Jaundice

54
Q

Practice question

How would you describe clubbing?

A
55
Q

Practice question

What characteristics of a skin lesion indicate malignancy and warrant further investigation?

A
56
Q

Practice question

When assessing inflammation and dark skin person, the nurse may need to

A Assess the skin for cyanosis and swelling.
B Assess oral mucosa for generalized erythema
C Palpate the skin for edema and increased warmth
D palpate the skin for tenderness and local area of ecchymosis

A

B. Assess the oral mucosa for cyanosis and swelling.

Oral mucosa shows better signs for altered color changes

57
Q

A nurse just noticed that a patient has a lesion that is confluent in nature. On examination, what would the nurse expect to find.

A. Lesions that run together
B. Annular lesions that have grown together.
C. Lesions arranged in a line along a nerve route.
D. Lesions that are grouped or clustered together.

A

B

58
Q

Practice question

The nurse is assessing the skin of a patient with AIDS and notices are widely disseminated, violet – colored tumor, covering the skin and mucous membranes. The nurse would suspect that:

A. She is in the first stage of AIDS
B. He is in the advanced stage of AIDS
C. He has been exposed to a viral infection.
D. He has an advanced case of herpes zoster.

A
59
Q

Practice question

The nurse has discovered, decreased skin turgar in a patient and knows that this is an expected, finding in which of the following conditions?

A. Cases of severe obesity.
B. During childhood growth spurts.
C. In an individual who is severely dehydrated.
D. Has a connective tissue disorder.

A

C.

60
Q

Practice question

52 – year – old woman has a papule on her nose that has rounded, pearly border and essential red ulcer. She said she has noticed it for several months and it has slowly grown larger. The nurse suspects which condition?

A. Acne.
B. Basal cell carcinoma.
C. Malignant melanoma.
D. Squamous cell carcinoma.

A
61
Q

Practice question

Match the following

-Petechiae
-Nodule
-Keloid
-Vesicle
-Ecchymosis

A

-Tiny punctate, hemorrhages, one to 3 mm, round and discrete, dark red, purple, or brown in color.

-A large patch of capillary bleeding and into tissues

-Hypertrophic scar

-Elevated cavity containing fluid, up to 1 cm. Clear serum flows if wall is ruptured.

-Solid, elevated, harder, soft, larger than one centimeter.

Nurse Assessment (6 decks)

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