Week 5: Integumentary, and Wound Assessment Flashcards
A person experiences a very painful paper cut to their finger. What layer(s) of skin is or are affected?
A. Epidermis only
B. Dermis only
C. Epidermis and dermis
D. Epidermis, dermis, and subcutaneous
C. The break in skin had to go through the epidermis (avascular layer) to the dermis layer. The dermis give the individual the ability to feel the pain of a papercut.
Areas to assess for color changes in dark-skinned patients
Conjunctiva, palm of hand, and mucous membranes
ABCDE for mole assessment
A: Asymmetry-draw a line through the middle of the two sides. Do they match?
B: Border-smooth, even?
C: Color- one color?
D: Diameter- small?
E: Evolving- does it change over time?
ABCDE: Abnormal findings
Asymmetry: Asymmetrical
Border: Uneven border
Color: Variety of colors
Diameter: Larger diameter
Evolving: Evolves
ABCDE: Normal findings
Asymmetry: Symmetrical
Border: Smooth
Color: One color
Diameter: Smaller diameter
Evolving: Look the same over time
Primary skin lesions
Lesions that occur in reaction to the external or internal environment. They may be present at birth or develop during an individual’s lifetime
Secondary skin lesions
Progressive changes in primary lesions, trauma, or injury to the primary lesion.
Macule: Lesion type and definition
Primary skin lesion
A circular, small, flat, nonpalpable spot less than 1 cm in diameter. Macules are red, brown, or white in color, and the color is not the same as that of nearby skin. They present in different shapes. Example: freckle.
Patch: Lesion type and definition
Primary skin lesion
Irregular, flat, nonpalpable macule greater than 1 cm. Example: Mongolian spots.
Vesicle: Lesion type and definition
Primary skin lesion
Raised, circumscribed, round, or oval with serous blood or clear fluid measuring less than 1 cm in diameter. Example: herpes zoster.
Pustule: Lesion type and definition
Primary skin lesion
A raised, circumscribed vesicle usually < 1 cm in diameter, and filled with pus. Infection is the primary cause. Example: acne.
Telangiectasia: Lesion type and definition
Primary skin lesion
Small, dilated blood vessels that occur near the surface of the skin. Example: rosacea.
Papule: Lesion type and definition
Primary skin lesion
A solid, elevated, spot that appears rough in texture and measures less than 1 cm in diameter. Papules are pink, red, or brown in color. Example: seborrheic keratosis.
Plaque: Lesion type and definition
Primary skin lesion
A patch of closely grouped thickened papules measuring greater than 1 cm across. Plaque is red, brown, or pink in color with a rough texture. Example: psoriasis.
Nodule: Lesion type and definition
Primary skin lesion
Solid, elevated, and palpable, measuring greater than 1.5 cm in diameter. Example: vascular nodule.
Bulla: Lesion type and definition
Primary skin lesion
Elevated, circumscribed, fluid filled, > 1 cm in diameter.
Tumor: Lesion type and definition
Primary skin lesion
Solid, elevated, and palpable, measuring greater than 2 cm; may vary in shape and size. Example: fatty lipoma.
Wheal: Lesion type and definition
Primary skin lesion
Defined by raised swelling, red bumps, or welts, and itchy skin. Wheals are red in color and are usually caused by an allergic reaction. Example: hives.
Scale: Lesion type and definition
Secondary skin lesion
A dry build-up of dead skin cells that usually flakes off the surface of the skin, such as in psoriasis.
Excoriation: Lesion type and definition
Secondary skin lesion
A hollow, crusted area with loss of the epidermis and an exposed dermis; may be caused by scratching the area, as in chronic incontinence.
Ulcer: Lesion type and definition
Secondary skin lesion
Concave, exudative, and variable in size. Ulcers erode different layers of the skin, such as in a pressure ulcer.
Scar: Lesion type and definition
Secondary skin lesion
Discolored fibrous tissue that appears over healed surgical incisions and wounds. Scars can be red, blue, white, and silver in color.
Moles: Lesion type and definition
Secondary skin lesion
A proliferation of melanocytes, is also called a nevus. Nevi is plural for nevus. Color is usually evenly pigmented in shades of brown with smooth borders. They measure less than 6 mm, and hair can grow out of them. Individuals average between 10 and 40 nevi.
Crust: Lesion type and definition
Secondary skin lesion
A dried collection of blood, serum, or pus; part of the normal healing process, such as in dried herpes zoster.
Erosion: Lesion type and definition
Secondary skin lesion
A depressed area that is moist and shiny. There is a loss of superficial epidermis, such as in candidiasis erosion.
Fissure: Lesion type and definition
Secondary skin lesion
A linear crack or break in the skin that involves the epidermal and dermal layers. They create small, deep, red fissures in the skin.
Keloid: Lesion type and definition
Secondary skin lesion
Created by excessive collagen production extending beyond the original boundaries of a wound or incision. It is thick and raised
2 types of moles
Clark’s nevi: Atypical moles are called dysplastic nevi or Clark’s nevi. They are larger with irregular, poorly defined borders. Color varies between shades of brown, tan, and pink. They have a greater potential for developing into melanoma.
Congenital nevi: Present at birth. They vary in size and can be greater than 10 cm and are categorized as small, medium or giant in size. Color is usually tan, brown, red, or shades of black.
Sequence of assessment for skin
- Inspection
- Palpation
Aspects of skin inspection (4)
- Hygiene
- Cyanosis in the lips, oral mucosa, tongue, and extremities
- Pallor of skin in the lips, fingernails, and mucous membranes
- Jaundice of skin in the lips, sclera of the eyes, and across the rest of the body
Aspects of skin palpation (4)
1.Palpate for temperature, comparing side to side using the dorsal surface of your hands
2.Palpate skin thickness. Remember that skin thickness varies. The thinnest skin is found on the eyelids, and the thickest areas of skin are found on the soles of the feet, palms of the hands, and elbows. Assess the hands and feet for calluses caused by pressure areas and rubbing
3.Palpate skin turgor. The best location to assess skin turgor is the clavicle area, but may also be done on the lower arm or abdomen. Pinch the skin between two fingers and let go. In a well-hydrated person, the skin returns to the flat position immediately. In the dehydrated person and someone who has lost a large amount of weight, the skin remains tented and slowly returns to the flat position
4.Palpate skin moisture
Distribution of lesions: Diffuse/generalized
Over the entire body
Distribution of lesions: Localized
Limited discrete area
Distribution of lesions: Regional, head
Confined to head
Distribution of lesions: Dermatome
Skin areas connected to spinal nerves
Distribution of lesions: Hairy areas
… self explanatory
Distribution of lesions: Scattered
Sparsely distributed
Distribution of lesions: Regional, torso
Confined to the torso
Distribution of lesions: Extensor surfaces
Elbows and kneecaps
Distribution of lesions: Intertriginous areas
Skin folds
Distribution of lesions: Sun-exposed areas
… self explanatory
Pattern of lesions: Round/oval
Coin shaped (eczema)
Pattern of lesions: Discrete
Lesions remain separate or apart (moles)
Pattern of lesions: Grouped
Grouped or clustered (HSV)
Pattern of lesions: Confluent
Lesions run together (measles)
Pattern of lesions: Linear
Lesions in lines (contact dermatitis, h. zoster)
Pattern of lesions: Arciform
Lesions in arcs, partial rings (syphilis)
Pattern of lesions: Iris
Bull’s eye rash (Lyme’s disease)
Pattern of lesions: Reticular
Meshlike rash (Lichen planus)
Pattern of lesions: Gyrate
Lesions in serpentine configuration (malignancy)
Pattern of lesions: Annular/circular
Lesions in ring shape (ringworm)
Pattern of lesions: Polycyclic
Coalesced, concentric circles (hives)
You are performing a skin assessment and note an irregular red lesion under a patient’s left armpit. What equipment will you need to assess the lesion? Select all that apply.
A. Personal protective equipment (gloves)
B. Paper tape measure
C. Penlight
D. Magnifying glass
E. Sterile cotton-tipped applicator
A, B, C, D
A: underarms may have perspiration.
B: lesion should be measured in centimeters.
C: better inspection.
D: identify characteristics and borders.
A bull’s-eye lesion, or round lesion with central clearing, is typical in Lyme disease. What is the name of this lesion’s pattern?
A. Round/oval
B. Iris
C. Confluent
D. Arciform
B
Iris pattern is a bull’s-eye lesion, or round lesion with central clearing, and is typical in Lyme disease.
Beau’s line
A white, horizontal groove across the nailbed, usually caused by disease, toxic reaction, or trauma.
Onychomycosis
Thickening, yellow discoloration, and scaling of the nailbed due to a fungal infection; more common in diabetics and older individuals
Paronychia
A skin infection around the nail causing erythema, swelling, and tenderness at the nail fold.
Pitting of nails
A sign of psoriasis; affects both fingernails and toenails; appears as indentations in different sizes, shapes, and depths; nails can disintegrate easily.
Splinter hemorrhages
Red streaks in the nails, caused by bleeding from capillaries under the nails.
Spoon nails
Flat or concave; outer edges flare out; dips or waves are visible on the surface of the nail; may be hereditary, related to a nutritional or systemic disease.
Wound drainage: Serous
Serum - Clear and watery
Wound drainage: Sanguineous
RBCs
Wound drainage: Serosanguineous
Serum and RBCs
Wound drainage: Purulent
WBCs, necrotic tissue debris - Dark yellow to green
4 phases of wound healing
Hemostasis, inflammatory, proliferation, remodeling
Phases of wound healing: Hemostasis
Occurs immediately after initial injury
Involved blood vessels constrict and blood clotting begins
Exudate is formed, causing swelling and pain
Increased perfusion results in heat and redness
Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Phases of wound healing: Inflammatory
Follows hemostasis and lasts about 2 to 3 days
White blood cells, predominantly leukocytes and macrophages, move to the wound
Macrophages enter the wound area and remain for an extended period. They ingest debris and release growth factors that attract fibroblasts to fill in the wound
Exudate is formed and accumulates, causing pain, redness, and swelling at the site of injury
The patient has a generalized body response
Phases of wound healing: Proliferation
Lasts for several weeks
New tissue is built to fill the wound space through the action of fibroblasts
Capillaries grow across the wound
A thin layer of epithelial cells forms across the wound
Granulation tissue forms a foundation for scar tissue development
Phases of wound healing: Remodeling
Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years
Collagen is remodeled
New collagen tissue is deposited, which compresses the blood vessels in the wound, causing a scar
Scar: flat, thin, white line; avascular collagen tissue that does not sweat, grow hair, or tan in sunlight
Stages of pressure ulcers: Stage I
Non-blanchable erythema; skin is intact
Stages of pressure ulcers: Stage II
Partial thickness loss involving both epidermis and dermis
Stages of pressure ulcers: Stage III
Full thickness loss; subcutaneous tissue/fat is visible
Stages of pressure ulcers: Stage IV
Full thickness loss; bone and muscle is visible
Stages of pressure ulcers: Unstageable
Eschar involved, unstageable until eschar is removed
Types of exudate: Slough
Yellow, a sign of necrotic tissue
Types of exudate: Eschar
Black, dehydrated necrotic tissue
6 elements of assessment when assessing a pressure ulcer
- Use the clock method to make linear measurements
- Wound perimeter
- Signs of inflammation
- Amount and color of exudate
- Tenderness
- Wound maceration
PUSH tool
Monitors change in pressure ulcer status over time
You are assessing a patient who does not walk and spends most of the day in a wheelchair. He is c/o left buttock pain. You put him back to bed and see a large excoriated, macerated open area on his left buttock. It measure 3 cm x 4 cm x 0.5 cm. What stage is this pressure ulcer?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B
An excoriation is a Stage II pressure ulcer—partial thickness loss involving both epidermis and dermis.
You are assessing a patient’s skin and note a silvery, scaly plaques on the patient’s knees and bilateral legs. He reports that he has a chronic immune disease. What skin condition is this patient most likely to have?
A. Acne
B. Psoriasis
C. Lupus Disease
D. Basal Cell Carcinoma
B
Psoriasis is a chronic immune disorder that causes the skin to develop silvery, scaly plaques.
You are assessing a 60-year-old patient who tripped going up the stairs. He reports 4/10 left leg pain and has a large 7 cm x 7 cm bruise on his right lower shin. What is the medical term for this bruise?
A. Purpura
B. Cherry Angioma
C. Hematoma
D. Ecchymosis
D
Ecchymosis is a bruise caused by bleeding under the skin or mucous membranes. It occurs as a result of local trauma.
Skin disorders with familial tendencies: Acne
An inflammatory disease of the sebaceous follicles of the skin, marked by comedones, papules, and pustules.
Skin disorders with familial tendencies: Skin cancer
A malignancy of the cells.
Skin disorders with familial tendencies: Eczema
A chronic inflammatory skin disorder that causes the skin to become scaly, itchy, inflamed, and irritated.
Skin disorders with familial tendencies: Lupus
A systemic autoimmune disease that occurs when the body’s immune system attacks their own tissues and organs, characterized by a distinctive facial butterfly rash unfolding across both cheeks.
Skin disorders with familial tendencies: Psoriasis
A chronic immune disorder that causes the skin to develop silvery, scaly plaques.
Skin disorders with familial tendencies: Seborrhea dermatitis
An inflammatory skin condition causing flaky, yellow scale to form on the scalp, ears, and face.
Changes in skin color: Albinism
Inherited disorder caused by the total or partial absence of an enzyme that produces melanin.
Changes in skin color: Carotenemia
A yellowing of the skin due to increased dietary intake of carotene in the diet, from foods such as carrots, sweet potatoes, pumpkin, corn, yams, spinach, and beans. The sclera of the eye does not become yellow.
Changes in skin color: Central cyanosis
Bluish discoloration to the skin related to decreased circulating oxygen; best assessed in the oral mucosa, conjunctiva of the eyes, lips, and tongue.
Changes in skin color: Erythema
Red, pink skin color; may indicate inflammation, fever, or increased blood flow. In carbon monoxide poisoning, the individual will have a bright red cherry face and upper trunk.
Changes in skin color: Jaundice
Yellowing of the skin due to excessive levels of bilirubin in the blood.
Changes in skin color: Hyperpigmentation
Darker skin color
Changes in skin color: Hypopigmentation
Lighter skin color
Changes in skin color: Pallor/pale
Pale skin is seen in anemia, a decrease in circulating red blood cells or blood flow, or absence of oxygenated blood.
Changes in skin color: Peripheral cyanosis
A blue, gray, slate, or dark purple discoloration of the skin or mucous membranes caused by deoxygenated or reduced hemoglobin in the blood; may occur with decreased cardiac output.
Changes in skin color: Vitiligo
Autoimmune disorder that causes smooth, white patches of skin all over the body.
