TOPIC 4 Flashcards
Epidermis
outermost layer of skin
Dermis
inner supportive layer (made of connective tissue/collagen and elastic tissue)
what are sweat glands important for
fluid balance and thermoregulation
eccrine glands
glands that produce sweat; found over most of the body
apocrine glands
sweat glands in the pubic and underarm areas that secrete thicker sweat, that produce odor when come in contact with bacteria on the skin
what are the functions of skin
o Protection from environment
o Prevents penetration (stops invasion of microorganisms and loss of water and electrolytes)
o Perception (touch, pain, temp, pressure)
o Temperature regulation
o Identification (no two finger prints are alike)
o Communication (blushing ans blanching indicate emotional distress)
o Wound repair
o Absorption and excretion
o Production of vitamin D
elasticity of skin in the aging adult
Loses elasticity; skin folds and sags (“parchment thin dry skin, wrinkle”)
sweat and sebaceous glands in the aging adult
decrease in number and function, leaving skin dry
senile purpura in the aging adult
discoloration due to increasing capillary fragility
vascularity of the sin decreases while fragility increases, making dark red areas on skin
skin breakdown sure to multiple factors in the aging adult
Cell replacement is slower and wound healing is delayed
hair matrix in the aging adult
Functioning melanocytes decrease, leading to gray fine hair
Genetic attributes of dark-skinned individuals afford protection against skin cancer due to ________.
melanin
keloids are more prevalent in
blacks, because of compact collagen bundles
what is the most important environmental risk factor for skin cancer?
exposure to ultraviolet (UV) radiation both from sun and tanning sources
Increased risk for melanoma related to
increased number of sunburns during one’s lifetime
health history questions for skin in aging adults
o What changes have you noticed in your skin in past few years?
o Any delay in wound healing?
o Any change in feet: toenails, bunions, wearing shoes?
o Falling: bruises, trauma?
o History of diabetes or peripheral vascular disease?
what equipment is needed for objective data collection of skin
o Strong direct lighting, gloves, penlight, and small centimeter ruler
o For special procedures
-Wood’s light
-Magnifying glass
-Materials for laboratory tests: potassium hydroxide (KOH) and glass slide
before you concentrate on outer structures of the skin….
scrutinize the outer skin surface
skin assessment is…
integrated throughout examination
intertriginous areas
areas with skinfolds
what is important about intertriginous areas
These areas are dark, warm, and moist and provide perfect conditions for irritation or infection, so separate them and inspect them
skin color assessment
o General pigmentation, freckles, moles, birthmarks
o Widespread color change
-Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow)
-Note if color change transient or due to pathology
where is the most reliable place to check color change is dark skinned people?
oral mucosa
pallor
pale; red tones for oxygenated hemoglobin lost
erythema
red; increased blood (hyperemia)
could indicate fever
cyanosis
blue; decreased perfusion (hyopemia)
jaundice
yellow; bilirubin in the blood
Skin temperature assessment
o Use backs of hands to palpate person
o Normal-warm, and temperature equal bilaterally; warmth suggests normal circulatory status
o Hands and feet may be slightly cooler in a cool environment
skin moisture assessment
o Diaphoresis
o Dehydration
What should raise concerns about physical abuse?
multiple bruises at different stages of healing and excessive bruises above knees or elbows
where would needle marks or tracks from IV injection of street drugs be visible?
antecubital fossae, forearms, or on any available vein
when a lesion is present, what should the nurse note?
o Color
o Elevation
o Pattern or shape
o Size
o Location and distribution on body
o Any exudate: note color and odor
o Use a Wood’s light (ultraviolet light filtered through special glass) to detect fluorescing lesions
primary lesions
develop on previously unaltered skin
secondary lesions
lesion changes over time because of scratching or infection
fluid accumulation in the interstitial spaces are
abnormal
where do you palpate and inspect for edema
Pretibial area
how long do you press when palpating and inspecting for edema
3-4 seconds
Scale to grade Pitting 1+
mild, slight indentation, no perceptible swelling
Scale to grade Pitting 2+
moderate, indentation subsides rapidly
Scale to grade Pitting 3+
deep, indentation remains for short time, appears swollen
scale to grade Pitting 4+
very deep, indentation lasts long time, appears very swollen
Wood’s light
detect flossing lesions (blue-green indicates fungal infection)
color of hair is due to
melanin production
texture of hair
oCharacteristics range from fine to thick to curly to straight and may be affected by use of hair care products
Tanner staging
Classification scheme for evaluation of development of primary and secondary sex characteristics (HAIR DISTRIBUTION)
Nail Normal Findings
Shape and contour-smooth, uniform-curved or flat
o Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees
capillary refill process
o Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation
o Color return is normally instant
o Sluggish color return takes longer than 1 or 2 seconds
abnormal clubbing
160 or less
rounded nail
ABCDE skin assessment
A: asymmetry
B: border (irreg border?)
C: color
D: diameter (larger than pencil eraser?)
E: elevation and enlargement
senile lentigines
dark-yellow or brown spots that develop on the skin as aging occurs
flat brown macule
hyperpigmentation
keratoses
raised thickened areas of epidermis (look crusty scaly warty)
xerosis
dry skin
acrohordons
skin tags
thin parchment
With aging, the skin looks as thin as parchment, and the subcutaneous fat diminishes. Thinner skin is evident over the dorsa of the hands, forearms, lower legs, dorsa of feet, and bony prominences. The skin may feel thicker over the abdomen and chest.
in aging the hair and nails are…
hair: decreased growth
nails: decreased nail and brittle nail
Inspection of the skin, hair, and nails
Color and pigmentation
Texture and distribution
Shape, contour, and consistency
Palpation of the skin, hair, and nails
Temperature and texture
Edema, mobility, and turgor
Note presence of lesions
Shape, configuration, and distribution
health promotion and skin
teach self examination
Annular or circular lesions
Begins in the center and spreads to the periphery (ex: ringworm)
confluent lesion
lesions run together (hives)
discrete lesions
distinct, individual lesions that remain separate
grouped lesions
lesions that appear in clusters
gyrate lesion
twisted, coiled spiral, snakelike
target or iris lesion
resembles iris of eye, concentric rings of color in lesions
linear lesions
a scratch, streak, line, or stripe
polycyclic lesions
annular lesions grow together (e.g., lichen planus, psoriasis).
Zosteriform lesion
linear arrangement along a unilateral nerve route (herpes zoster-shingles)
macules
Solely a color change, flat and circumscribed, of less than 1 cm. “Freckle”
papules
Firm raised circumscribed areas on the skin <1cm (mole)
patches
macules that are larger than 1 cm
plaques
coalesce to form surface elevation wider than 1 cm. A plateau like, disk-shaped lesion
nodules
Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi.
wheal
superficial, raised, transient, and erythematous; slightly irregular shape from edema (hive or mosquito bite)
tumor
larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant
urticaria
wheals coalesce to form extensive reaction, intensely pruritic (hives)
vesicles
elevated cavity containing free fluid up to 1 cm (“blister”)
Clear serum, flows if wall is ruptured (chicken pox)
bulla
a large blister that is usually more than 1 cm in diameter (burns, friction blister)
cyst
encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin (subceous cyst)
pustules
Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne.
what are the primary skin lesions
Macule, papule, patch, plaque, wheal, nodule, tumor, vesicle, bulla, pustule, cyst
what are the secondary skin lesions
crusts, scales, fissures, erosions, ulcers, excoriations, scares, atrophic scars, lichenifications, keloids
crusts
thickened, dried out exudate left when vesicles/pustules burst or dry up (impetigo)
scales
compact desiccates flakes of skin, dry or greasy, silvery or white from shedding of dead excess keratin cells (eczema, psoriasis)
fissures
linear crack with abrupt edges (athletes foot)
erosions
Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis.
ulcers
deeper depression extending into dermis, irregular shape, may bleed. leaves scar when heals
excoriations
self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching
scars
after a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen)
atrophic scars
the resulting skin level is depressed with loss of tissue; a thinning of the epidermis “stretch marks”
Lichenification
Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)
keloids
benign overgrowths of fibrous tissue at the site of a scar or trauma
hemangioma
Caused by a benign proliferation of blood vessels in the dermis.
Port-Wine Stain (Nevus Flammeus)
A large, flat, macular patch covering the scalp or face, frequently along the distribution of cranial nerve V.
The color is dark red, bluish, or purplish and intensifies with crying, exertion, or exposure to heat or cold.
The marking consists of mature capillaries.
It is present at birth and usually does not fade.
Strawberry Mark (Immature Hemangioma)
A raised bright red area with well-defined borders about 2 to 3 cm in diameter. It does not blanch with pressure.
It consists of immature capillaries, is present at birth or develops in the first few months, and usually disappears by age 5 to 7 years.
Cavernous Hemangioma (Mature)
reddish-blue, irregularly shaped, solid and spongy mass of blood vessels
Telangiectasia
Caused by vascular dilation; permanently enlarged and dilated blood vessels that are visible on the skin surface.
spider or star angioma
fiery red, star-shaped marking with a solid circular center
venous lake
blue-purple dilation of venules and capillaries in a star-shaped, linear, or flaring pattern
purpuric lesions
purpura; lesions resulting from hemorrhages into the skin. Difficult to see in dark skinned people
petechiae
pinpoint purple or red spots from minute hemorrhages under the skin
purpura
Confluent and extensive patch of petechiae and ecchymoses; >3 mm, flat, red to purple, macular hemorrhage.
Seen in generalized disorders such as thrombocytopenia and scurvy.
Also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis.
pattern injury
bruise or wound whose shape suggests the instrument or weapon that caused it
Hematoma
a solid swelling of clotted blood within the tissues.
Contusion (bruise)
A mechanical injury (e.g., a blow) results in hemorrhage into tissues.
5 bruise steps
- 1 - Red-blue or purple immediately after or within 24 hours of trauma
- 2 - Blue to purple
- 3 - Blue-green
- 4 - Yellow
- 5 - Brown to disappearing
on a dark skinned individual what color is their bruise
deep dark purple
stage I pressure ulcer
intact skin, red, unbroken, localized redness, lighter skin-does not blanch, darker skin remains darker-does not blanch
stage II pressure ulcer
Partial thickness erosion, loss of epidermis, shallow abrasion or open blister looking, red-pink wound bed
Stage III pressure ulcer
full thickness extending into SQ, crater like, fat may be visible
stage IV pressure ulcer
full thickness, all layers to supporting structures, muscle, tendon, bone, slough and eschar
light vs dark skin: cyanosis color
light: grayish blue tone
dark: ashen gray color
light vs dark skin: cyanosis location
light: nail beds, earlobe, lips, mucous membranes, palms, soles
dark: conjunctiva of the eye, oral mucous membranes, and nail beds
light vs dark skin: ecchymosis (bruise) color
light: Dark red, purple, yellow, or green color, depending on age of bruise
Dark: Deeper bluish or black tone; difficult to see unless it occurs in an area of light pigmentation
light vs dark skin: erythema color
light: Reddish tone with evidence of increased skin temperature secondary to inflammation
dark: Deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation
light vs dark skin: jaundice color and location
light: Yellowish color; skin, sclera of eyes, fingernails, palms of hands, and oral mucosa
dark: Yellowish-green color most obviously seen in sclera of eye (do not confuse with yellow eye pigmentation, which may be evident in dark-skinned patients), palms of hands, and soles of feet
light vs dark skin: pallor color
light: Pale skin color that may appear white
dark: Skin tone appears lighter than normal; light-skinned African Americans may have yellowish-brown skin; dark-skinned African Americans may appear ashen; specifically evident is a loss of the underlying healthy red tones of the skin
light vs dark skin: petechiae color
light: Lesions appear as small, reddish-purple pinpoints
dark: Difficult to see; may be evident in the buccal mucosa of the mouth or sclera
light vs dark skin: rash
light: May be visualized and felt with light palpation
dark: Not easily visualized but may be felt with light palpation
light vs dark skin: scar
light: Narrow scar line
dark: Frequently has keloid development, resulting in a thickened, raised scar
