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Nursing Assessment > Integumentary > Flashcards

Integumentary Flashcards

1
Q

Seborrhea

A

Oily skin

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2
Q

Petechiae

A

Tiny pinpoint (<3mm) hemorrhages, superficial bleeding from capillaries under skin

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3
Q

Pallor

A

Pale or lighter skin color than usual.

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4
Q

Pruritus

A

Intense itching causing the desire to scratch

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5
Q

Pigmentation

A

Skin color

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6
Q

Vitiligo

A

Skin areas without usual brown pigment

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7
Q

Urticaria

A

Hives, skin rash with red, raised, itchy bumps.

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8
Q

Xerosis

A

Dry skin

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9
Q

Nevus

A

Mole

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10
Q

What layer of skin contains blood vessels, hair follicles, and nerve endings?

A

Dermis

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11
Q

True or false: The dermis is composed of thick fibrous connective tissue?

A

True: The demis is composed of a thick fibrous protein called collagen that provides flexibility to resist tearing with movement.

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12
Q

What layer of the skin prevents water loss?

A

Epidermis

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13
Q

What layer of the skin secretes melanin?

A

Epidermis

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14
Q

What layer of skin contains fat stores for energy?

A

Subcutaneous

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15
Q

Hypopigmentation

A

Decrease in skin color

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16
Q

Hyperpigmentation

A

Increase in skin color

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17
Q

Cyanosis

A

Bluish color of skin

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18
Q

Ecchymosis

A

Bruises, spot or blotch larger than petechiae. Also called contusions

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19
Q

Hematoma

A

Blood clot in organ space, or tissue – raised

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20
Q

Diaphoresis

A

Profuse perspiration

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21
Q

Jaundice

A

Yellow color of skin, caused by increase in bilirubin

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22
Q

Edema

A

Swelling, presence of excess interstitial fluid.

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23
Q

Erythema

A

Inflammation of skin atea

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24
Q

Purpura

A

Collection of petechia and ecchymosis covering an area.

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25
Q

Macule

A

Primary lesion, flat, area of pigment change less than 1cm
Ex: freckle, mole, measles, scarlet fever
Petichiae can be a type of macule, but specifically vascular

26
Q

Patch

A

Primary lesion, flat, pigment change greater than 1 cm

Ex: birthmark, vitiligo, cafe au lait > 1 cm

27
Q

Papule

A

Primary lesion, raised, less than 1 cm

Ex: Wart, skin tag, elevated mole

28
Q

Plaque

A

Primary lesion, raised, greater than 1cm area (usually well defined with clear borders)
Ex: psoriasis, eczema

29
Q

Wheal

A

Primary lesion, raised/solid, irregular area of edema on the skin
Ex: bug bites, allergic reaction, hives

30
Q

Nodule

A

Primary lesion, raised/solid, <2 cm firm area originating from deeper in the dermis.
Ex: melanoma, hemangioma

31
Q

Tumor

A

Primary lesion, raised/solid, >2 cm firm area originating deeper in the dermis.
Ex: Lipoma, neoplasm

32
Q

Vesicle

A

Primary lesion, raised/fluid filled, superficial, <1 cm filled with serous fluid
Ex: chicken pox, shingles, herpes simplex

33
Q

Bulla

A

Primary lesion, raised/fluid filled, >1 cm, superficial, filled with serous fluid
Ex: blister, medication reaction

34
Q

Pustule

A

Primary lesion, raised/fluid filled, <1cm, filled with purulent fluid
Ex: acne

35
Q

Cyst

A

Primary lesion, raised/fluid filled, encapsulated arising from the dermis or subcutaneous layer, filled with liquid or semi-solid fluid
Ex: cystic acne, sebaceous cyst

36
Q

ABCDE Rules for Skin Cancer

A 
A = asymmetry
B = border, irregular
C = color variation
D = diameter >6mm, or a pencil eraser
E = evolving, changing in size, composition, or color
37
Q

Reddened area that does not blanch with pressure, has a different texture (firmer or softer) or different temperature (warmer or cooler) than surrounding tissue.

A

Stage I pressure ulcer

38
Q

Partial loss of dermis with shiny or dry pink wound bed and may present as an intact or ruptured blister.

A

Stage II pressure ulcer

39
Q

Full thickness skin loss with damage or necrosis of the subcutaneous tissue. Subcutaneous fat may be visible. Dead tissue may be present in wound bed,

A

Stage III pressure ulcer

40
Q

Full thickness skin loss with exposed bone, muscle, or tendon. Dead tissue may be present in the wound bed.

A

Stage IV pressure ulcer

41
Q

Mottled

A

marbled appearance that may be baseline but can be related to poor circulation or cardiovascular issues

42
Q

two places to check for pallor regardless of skin tones

A

conjunctival sac, oral and buccal membranes

43
Q

what to palpate erythema for

A

increased warmth, induration, tautness

44
Q

places to check for early jaundice

A

junction of soft and hard palates, sclera, blanched forehead (usually starts at head, then trunk, then extremities)

45
Q

central/circumoral cyanosis is an [early/late] sign of cyanosis

A

late – they probably need oxygen.

46
Q

occurring in a straight line

A

linear: can be discrete or confluent

47
Q

arcs or rings

A

arciform: can be annular – ringlike with raised borders around round, flat clear center

48
Q

circular

A

circunate

49
Q

several lesions grouped together

A

clustered or grouped

50
Q

with wavy borders, snakelike aka gyrate

A

serpiginous

51
Q

scale

A

secondary: shedding dead skin cells, may be dry and loose or oily and adherent.
ex: psoriasis

52
Q

fissure

A

secondary: linear cleft in the skin extending through epidermis into the dermis, they usually occur when skin is dry and thickened. Often seen in heels, between fingers and toes, sides of mouth

53
Q

excoriation

A

secondary: loss of outer skin layers from itching or rubbing
ex: scratched insect bite

54
Q

erosion

A

secondary: loss of epidermis that does not extend into dermis
ex: popped blister, ruptured chicken pox vesicle

55
Q

keloid

A

palpable fibrous overgrowth after the scar formation

56
Q

hemangioma

A

benign proliferation of blood vessels in the dermis

57
Q

purpura

A

flat macular hemorrhage under skin, does not blanche, 3-10 mm, possibly raised

58
Q

places to check for skin turgor

A

under clavicle (preferred) or on dorsal surface of hand

59
Q

hirsutism

A

excessive growth of hair or hair in unusual places (can be related to hormonal imbalances)

60
Q

clubbed nails

A

can be from chronic hypoxia

61
Q

which direction is the clock oriented for documenting wounds?

A

noon is towards the head

Nursing Assessment (13 decks)

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