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
