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Health Assessment NUR 202 > CH 13: Skin Hair Nails and Wounds > Flashcards

CH 13: Skin Hair Nails and Wounds Flashcards

1
Q

what is the largest organ?

A

skin

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2
Q

what does skin do?

A

first line defense
protects
supports
adapts

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3
Q

when do you conduct skin assessment?

A

ongoing during physical exam, part of general survey

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4
Q

skin structure?

A

epidermis
dermis
SUBQ

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5
Q

epidermal appendages?

A

hair
sebaceous glands
sweat glands (eccrine and apocrine)
nails

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6
Q

aging skin?

A

drier, thinner, flatter
decreased:
sebum/sweat
elasticity
functioning melanocytes
elastin/collagen
form new collagen
changes in:
temp regulation
nails
hair
circulation
skin lesions common
increased damage risk

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7
Q

effectors of skin condition?

A

thin
obese (skin folds)
fluid loss
excessive perspiration
diseases
inability to sense temp
nutrition deficits

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8
Q

health state effectors?

A

diabetes (more at risk for yeast infection, delayed wound healing)
GI probs
bed rest
casts
meds
lifestyle
piercings
urine/stool (can cause skin breakdown bc acidity)

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9
Q

skin integrity alterations?

A

external pressure- compresses BV
friction/shear- tear or injure BV or damages top layer
bony prominences- pressure ulcer
moisture
mental status
nutrition/hydration
age

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10
Q

braden scale categories?

A

sensory perception
moisture
activity
mobility
nutrition
friction and shear
1-4 scale (4 no impairment)

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11
Q

stage 1 pressure injury?

A

erythema of skin
nonblanchable
skin intact

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12
Q

stage 2 PI?

A

erythema with loss of partial thickness including epidermis and part of superficial dermis
presents as abrasion or blister

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13
Q

stage 3 PI?

A

full thickness, may involve SUBQ fat
presents as deep crater
skin completely gone

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14
Q

stage 4 PI?

A

full thickness, involves muscle or bone
tissue necrosis
“tunneling”

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15
Q

unstageable?

A

can’t stage, unknown deepness

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16
Q

Color classification: red?

A

protect*
proliferative stage and reflect healthy healing
interventions: gentle cleaning, moist dressing, changing dressing

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17
Q

Color classification: yellow?

A

cleanse*
may indicate exudate drainage or slough
oozing from tissue
drainage: whitish yellow, cream yellow, yellowish green, beige
interventions: irrigating, wet to moist dressing, nonadherent dressing, antimicrobial topicals

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18
Q

Color classification: black?

A

debride*
presence of eschar (necrotic tissue) brown, black, gray, tan
requires debridement (removal) for healing

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19
Q

eschar removal?

A

mechanical debridement? scalpel or scissors to cut dead tissue, scrub wound
chemical? collagenase enzyme agent or autolytic (helps body produce enzymes to break down)

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20
Q

wound/lesion documentation?

A

color
edges
size and shape
depth/tunnels/raised
odor
clock method
drainage
treatment method

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21
Q

subjective skin data?

A

previous hx
mole changes
pigment changes
excessive dryness or moisture
pruritus
excessive bruising

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22
Q

health hx questions?

A

rash/lesions
meds
hair loss
nail changes
environmental/occupational hazards
self care

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23
Q

objective data assessment supplies?

A

need:
gloves
tape/ruler
penlight
lighting

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24
Q

2 key components of physical exam? - what do you do?

A

inspection and palpation

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25
Q

pallor?

A

pale

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26
Q

erythema?

A

red

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27
Q

cyanosis?

A

blue

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28
Q

jaundice?

A

yellow
(excess bilirubin)

29
Q

how to assess for inflammation?

A

palpate for edema and warmth

30
Q

jaundice assessment for darker skin?

A

sclera/conjunctivae and mucous membranes
(eyes and inside mouth)

31
Q

petechia?

A

small red dots (bruising) from burst capillaries

32
Q

how to assess temp?

A

back (dorsum) of hand
hypothermia: low temp
hyperthermia: high temp

33
Q

moisture abnorms?

A

diaphoresis: excessive sweating
dehydration (skin turgor)

34
Q

inspect and palpate for?

A

texture
thickness
edema
mobility/turgor
vascularity
bruising

35
Q

tests for edema?

A

protein: keeps fluid in vascular system
malnourished=hypoprotein
use liver panel (albumin and complete protein) if a lot of fluid (swollen, ascites)
anasarca? overall fluid state

36
Q

assess lesions for?

A

color
elevation
pattern/shape
size
location
distribution
exudate

37
Q

assess hair for?

A

color
texture
distribution
lesions

38
Q

assess nails for?

A

shape/contour
consistency
color
cap refill (under 3= brisk, over 3= sluggish)

39
Q

ABCDE rule?

A

asymmetry
border
color
diameter
elevation

40
Q

annular/circular?

A

begins in center, spreads around periphery- larger over time

41
Q

confluent?

A

run together

42
Q

discrete?

A

distinct and separate

43
Q

grouped?

A

clustered

44
Q

gyrate?

A

twisted, coiled, snakelike

45
Q

target?

A

“bullseye” concentric rings
ex. lyme, tics

46
Q

linear?

A

scratch, line, streak

47
Q

polycyclic?

A

annular that grow together

48
Q

zosteriform?

A

linear arrangement follows unilateral nerve route

49
Q

purpura?

A

confluent and extensive patch of petechiae (less than 4 mm) and ecchymosis (larger than 1 cm)

50
Q

hematoma?

A

bad bruise with pooling blood

51
Q

necrosis?

A

cell death

52
Q

striae?

A

dermal scarring (stretch marks)

53
Q

macule?

A

solely color change, flat, less than 1 cm
ex. freckles

54
Q

patch?

A

macule larger than 1 cm
ex. vitiligo

55
Q

papule?

A

elevated, less than 1 cm
ex. mole

56
Q

plaque?

A

papules coalesce
ex. psoriasis

57
Q

nodule?

A

solid, elevated, larger than 1 cm
ex. fibroma

58
Q

wheal?

A

superficial, raised, slightly irregular
ex. mosquito bite

59
Q

vesicle?

A

elevated cavity containing free fluid
ex. blister

60
Q

cyst?

A

encapsulated fluid filled cavity

61
Q

pustule?

A

turbid fluid in cavity (pus)
ex. acne

62
Q

crust?

A

thickened, dried exudate
ex. scab

63
Q

scale?

A

compact desiccated flakes
ex. psoriasis

64
Q

fissure?

A

linear crack
ex. cheilosis (cracks in mouth corners)

65
Q

excoriation?

A

inflammation from friction or reaction- self inflicted
ex. scabies

66
Q

keloid?

A

benign excess scar tissue
ex. surgery, acne, piercings

67
Q

what can lead to clubbing?

A

long term hypoxia from COPD (hypoperfusion to extremities)

68
Q

abdomen checklist?

A

inspection: contour, symmetry, umbilicus, skin, pulsation
auscultation: bowel sounds
percussion: all four quadrants and liver/spleen borders
palpation: light and deep

Health Assessment NUR 202 (17 decks)

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