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health assessment > Unit exam 2 > Flashcards

Unit exam 2 Flashcards

1
Q

What is the largest organ of the body?

A

the skin

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2
Q

What are the two layers of the skin?

A
  • Epidermis: outer highly differentiatd layer
    • basal cell layer forms new skin cells
    • outer horny cell layer of dead keratinized
      cells
  • Dermis: inner supportive layer
    • connective tissue or collagen
    • elastic tissue

** beneath these layers is a subcutaneous layer of adipose tissue

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3
Q

What are some functions of the skin?

A
  • it is waterproof, protective, and adaptive
  • protection from environment
  • perception
  • temp regulation
  • identification
  • communication
  • wound repair
  • absorption and excretion
  • production of vitamin D
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4
Q

What is ichthyosis Vulgaris?

A
  • is an inherited skin disorder in which dead skin cells accumulate in thick, dry scales on your skin’s surface.
  • tough skin
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5
Q

What are subjective data health history questions?

A
  • past history of skin disease, allergies, hives, psoriasis, or eczema?
  • change in pigmentation?
  • excessive dryness or moisture?
  • pruritus or skin itching?
  • excessive bruising?
  • rash or lesions?
  • medications?
  • hair loss?
  • change in nails?
  • self-care bxs?
  • environmental or occupational hazards?
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6
Q

What are health history questions for adolescents?

A

skin problems such as pimples or blackheads?

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7
Q

What are health history questions for aging adults?

A
  • what changes have you noticed in your skin in past few years?
  • any delay in wound healing?
  • any change in feet?
  • falling?
  • history of diabetes or peripheral vascular disease?
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8
Q

What is the complete physical exam?

A
  • skin assessment integrated throughout exam
  • separate areas with skinfold such as under large breasts, obese abdomen, and groin, and inspect them thoroughly
  • always inspect feet, toenails, and between toes
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9
Q

How can you inspect and palpate the skin?

A
  • Color
  • General pigmentation, freckles, moles, birthmarks
  • 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
  • Temperature
  • Use backs of hands to palpate person…why?
  • Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status
  • Hands and feet may be slightly cooler in a cool environment
  • –Hypothermia
  • –Hyperthermia
  • Moisture
  • Diaphoresis
  • Dehydration
  • Texture
  • Thickness
  • Edema
  • Mobility and turgor
  • Vascularity or bruising
  • —Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse
  • —Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae, forearms, or on any available vein
  • Lesions: if any are present, note the following:
  • Color
  • Elevation
  • Pattern or shape
  • Size
  • Location and distribution on body
  • Any exudate: note color and odor
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10
Q

What are some color changes of the skin?

A
  • Raynauds - a problem that causes decreased blood flow to the fingers; causes blue or white fingers
  • Jaundice - yellow skin
  • Cyanosis - a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
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11
Q

What are the stages of bruising?

A

bruise –> hemoglobin –> bilierdin –> biliruben –> healing

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12
Q

What is the bruise age by color?

A 
Red - 0-2 days 
Blue, purple - 2-5 days 
green - 5-7 days 
yellow - 7-10 days 
brown - 10-14 days 
no further evidences of bruising 2-4 weeks
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13
Q

Types of wound exude: serous

A

clear, amber, thin, and watery

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14
Q

Types of wound exude: fibrinous

A

cloudy and thin, with strand of fibrin

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15
Q

Types of wound exude: serosanguineous

A

reddish, thin and watery

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16
Q

Types of wound exude: seropurulent

A

yellow or tan, cloudy and thick

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17
Q

Types of wound exude: purulent

A

opaque, milky; sometimes green

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18
Q

Types of wound exude: hemopurulent

A

reddish, milky and viscous

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19
Q

Types of wound exude: hemorrhagic

A

red and thick

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20
Q

What is ABCDE of skin assessment?

A 
A: asymmetry
B: border
C: color
D: diameter
E: elevation and enlargement
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21
Q

What are some different shapes and configurations of lesions?

A
  • Circular
  • Confluent: joining or running together
  • Discrete: made up of separated parts or characterized by lesions which do not become blended. In the same area but are not touching
  • Grouped
  • Linear
  • Zosteriform: resembling herpes zoster
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22
Q

What is a macule?

A
  • flat, distinct discolored areas less than 1 cm
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23
Q

What is a papule?

A
  • Elevated, circumscribed and firm
  • lesions, <1 cm in diameter
  • Warts and drug related eruptions are papules
  • Various colors including brown, red, pink, tan and bluish red
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24
Q

What is a nodule?

A
  • <1 cm in diameter
  • Similar to papules, but deeper
    in dermis and feel firmer on
    palpation
  • Fibromas and intradermal
    nevi
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25
Q

What is a wheal?

A
  • Vary in size and shape
  • Elevated, irregular, and relatively
    transient
  • Mosquito bite causes wheal
  • Hives are multiple wheals that usually cause severe itching from some sort of hypersensitive reaction.

***TB test elevation bubble

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26
Q

What is a vesicle?

A
  • Circumscribed; <1 cm in diameter
    • Elevated and filled with serous fluid.
    • Blisters and varicella lesions are examples
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27
Q

What is a bullae?

A
  • vesicles >1 cm
    – Rupture easily because of their
    thin walls
    – Large blisters from 2nd degree
    burns may be classified as bullae
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28
Q

What is a cyst?

A
  • Nodules filled with liquid or semisolid material
  • Can be expressed
  • Example – sebaceous cyst
29
Q

What is a pustule?

A
  • similar to vesicles
  • filled with purulent rather than serious fluid
  • acne and impetigo cause pustules
30
Q

What are patches?

A
  • Differ from macules
  • Irregular shape
  • > 1 cm in diameter
  • Port-wine marks are examples (Sam’s birth mark on his leg)
  • Vitiligo – otherwise normal skin with non-pigmented white patches
31
Q

What are plaques?

A
  • Elevated like papules but >1 cm
  • Firm and rough
  • Often formed by coalesced papules (psoriasis)
32
Q

What is a tumor?

A
  • Larger than nodules, >1 cm on surface
  • Deeper in dermis than nodules
  • May or may not be demarcated, firm, or malignant
33
Q

What are some examples of a break in the continuity of skin surface?

A 
Fissures
Erosions
Ulcers
Excoriations
Scars
Atrophic scars
Lichenifications - skin has become hardened and leathery, usually from chronic irritation. 
Keloids - raised type of scar, usually after an injury that has healed. Grow much larger than original injury that caused the scar.
34
Q

What are some examples of debris on the skin surface?

A

CRUST

  • Dried collection of blood, pus, serum
  • Slightly elevated
  • Vary in size and color
  • May also be called a scab

SCALES

  • Dry buildup of dead skin cells
  • Often flakes off surface of skin
  • Irregular and variable in size
  • Fungal infections, psoriasis, eczema
35
Q

What is a fissure?

A
  • Linear breaks in the skin extending from epidermis to dermis
  • Small, deep and red
  • Tinea pedis (athlete’s foot) produces fissures
36
Q

What is erosion?

A
  • Resemble excoriations
  • Depressed area is moist and glistening
  • Follow vesicular rupture (varicella)
37
Q

What is excoriation?

A
  • Loss of epidermis, leaving exposed dermis
  • May be linear or be hollowed out
  • Example - abrasions
38
Q

What is a scar?

A
  • Collagenous tissues that permanently
    replace injured dermis
  • Vary in size and color
  • Progressively enlarging scars growing beyond original boundaries are called keloids
39
Q

What is a keloid?

A
  • caused by excess deposition of collagen in a healing wound
  • are benign tumors, and the tendency to develop keloids is inherited
  • African Americans are more susceptible.
40
Q

What is lichenification?

A
  • Thickening of epidermis
  • Caused by chronic rubbing and scratching
  • Chronic dermatitis/callous
41
Q

What is an ulcer?

A
  • Concave, exudative
  • Deep erosions that involve dermis and may involve below
  • Variable in size
42
Q

What is atrophy?

A
  • thinning of skin
  • translucent and paper like
  • striae (stretch marks)
43
Q

What are different vascular lesions?

A
  • Hemangiomas
    • port-wine stain
    • strawberry mark
    • cavernous hemangioma
  • Telangiectases
    • spider or star angioma
    • venous lake
  • Purpuric lesions
    • petechiae
    • purpura
  • Lesions caused by trauma or abuse
    • pattern injury
    • hematoma
    • contusion (bruise)
  • Ecchymosis – bleeding into skin, not traumatic, > 1 cm
  • Hematoma – same, but raised
  • Petechiae – tiny hemorrhages from capillaries
  • Purpura – confluence of petechiae and ecchymosis
  • Mechanical injury – blunt force trauma causes hemorrhage into tissues.
44
Q

What are things that can exacerbate a Pressure ulcer?

A 
Moisture
Impaired mobility
thin skin
Decreased sensation(neuropathy, paraplegic, post stroke, spinal cord damage, MS)
Impaired loc/comprehension 
Incontinence
Wound drainage
Shearing injury 
Poor nutrition 
Infection
Low albumin level
Compromised blood flow (PAD, shock, venous insufficiency)
Skin color…hard to see changes In skin 
Bony prominences
Age
45
Q

What is the stage 1 of a pressure ulcer?

A
  • Pressure Injury: Non-blanchable erythema of intact skin
  • Intact skin
  • localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.
  • Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
46
Q

What is the stage 2 of a pressure ulcer?

A
  • Partial thickness skin loss with exposed dermis
  • wound bed is viable, pink or red, moist, and may also present as an
  • intact or ruptured serum-filled blister.
  • Superficial
  • Abrasion, blister, shallow crater
47
Q

What is the stage 3 of a pressure ulcer?

A
  • Full thickness skin loss
  • adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present
  • Damage or necrosis of subcutaneous tissue
  • Slough and/or eschar may be visible
  • Presents as deep crater with or without undermining and tunneling of adjacent tissues
  • Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.
  • If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury
48
Q

What is the stage 4 of a pressure ulcer?

A
  • Full thickness skin loss and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer
    E- xtensive destruction, tissue necrosis or damage to muscle, bone or supporting structures
  • Slough and/or eschar may be visible.
  • Undermining and sinus tracts possible
49
Q

What is tunneling?

A

narrow opening or passageway that can extend in an direction through soft tissue and result in dead space with potential of abscess formation. Also known as a sinus tract.

50
Q

What is undermining?

A

the destruction of the underlying tissue surround some or all of the wound margins. May extend in one or many directions underneath the wound edge

51
Q

What is Senile purpura?

A

Discoloration due to increasing capillary fragility

52
Q

What do you inspect and palpate for nails?

A
  • shape and contour
  • consistency
  • color
  • capillary refill
53
Q

What is paronychia?

A
  • Inflammation of the skin around the nail
  • Characterized by swelling, sometimes redness and tenderness

Acute – usually bacterial
Chronic – usually fungal

54
Q

What is a splinter hemorrhage?

A
  • Red or brown linear streaks parallel to the long axis of the nail
  • Have been associated with sub-bacterial endocarditis or minor trauma
55
Q

How can you inspect and palpate the skull?

A
  • Note general size and shape
  • Assess shape: place fingers in person’s hair and palpate scalp
  • Skull normally feels symmetric and smooth
  • There is no tenderness to palpation
  • Palpate temporomandibular joint as the person opens the mouth, and note normally smooth movement with no limitation or tenderness
56
Q

How can you inspect the face?

A
  • Note facial expression and appropriateness to behavior or reported mood
  • Facial structures always should be symmetric
  • Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth
  • Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation), or abnormal swellings
  • Note any involuntary movements (tics) in facial muscles; normally none occur
57
Q

What is the thyroid gland?

A
  • an important endocrine gland straddles trachea in middle of the neck
  • The gland has two lobes, connected in middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring
  • Synthesizes and secretes thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism
58
Q

How can you inspect and palpate the neck?

A
  • Symmetry
  • Range of motion
  • Lymph nodes
  • Trachea
  • Thyroid gland
  • Posterior approach
  • Anterior approach
  • Auscultate thyroid for bruit, if enlarged
59
Q

What is the lymphatic system?

A
  • an extensive vessel system, is major part of immune system, which detects and eliminates foreign substances from body
  • Vessels allow flow of clear, watery fluid from tissue spaces into circulation
  • Nodes are small, oval clusters of lymphatic tissue that filter lymph and engulf pathogens, preventing potentially harmful substances from entering the circulation
  • Greatest supply is in head and neck
    You should be familiar with direction of drainage patterns of lymph nodes
60
Q

Flexion

A

chin to chest

norm about 45 degrees

61
Q

Extension

A

chin to ceiling (55 degrees)

62
Q

Rotation

A

chin to shoulder (70 degrees)

63
Q

Lateral

A

ear to shoulder (40 degrees)

64
Q

What are some abnormal facial appearances?

A
  • Parkinson syndrome
  • Cushing syndrome
  • Graves’ disease
  • Hyperthyroidism
  • Myxedema (hypothyroidism)
  • Bell’s palsy
  • Brain attack or cerebrovascular accident
  • Cachectic appearance
  • Scleroderma
65
Q

What is graves disease?

A

Autoimmune disease that causes hyperthyroidism (Active thyroid)

66
Q

What is goiter?

A

abnormal enlargement of thyroid gland

67
Q

What is bells palsy?

A

Caused by trauma to 7th cranial nerve. ½ face is paralyzed or weakened.

68
Q

What is cachexia?

A

Means bad condition. Physical wasting with loss of muscle and mass due to disease. Advanced cancer, AIDS, severe heart failure.

health assessment (4 decks)

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