Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NSG2317 - health assessment > Ingetumentary Assessment > Flashcards

Ingetumentary Assessment Flashcards

1
Q

Functions of the Skin (9)

A
  1. Protection
  2. Prevention of Penetration
  3. Perception
  4. Temperature Regulation
  5. Identification
  6. Communication
  7. Wound Repair
  8. Absorption and Excretion
  9. Production of Vitamin D
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Older Adult Considerations: Skin

A

the skin reflects the changes that all organs experience as a result of aging → slow atrophy of skin structures

  1. Elastin, collagen, and subcutaneous
    fat, and muscle tone are lost
    -The loss of collagen increases
    the risk of shearing and tearing
    injuries
    - Healing is prolonged
  2. The outer layer of the epidermis
    thins and flattens → wrinkling
    occurs because the underlying
    dermis also flattens
  3. Sweat and sebaceous glands
    decrease in number, leaving the
    skin dry
    - Decreased response of the
    sweat glands to temperature
    increase leaves older adults at
    an increased risk for heat stroke
    (cannot regulate temperature,
    cool down)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Older Adult Considerations: Hair

A

hair loss on the scalp is genetically determined

  1. The number of functioning melanoxytes decreases, so hair turns grey or white → thin and finea. Males have some symmetrical W-
    shapped balding in the frontal
    areas
    b. Women may have some bristly
    facial hairs as estrogen levels
    decrease (testosterone is more
    prominent)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Older Adult Considerations: Nails

A

growth rate decreases
- The surface of nails are lustreless
and characterized by longitudinal
ridges that result from local
trauma at the nail matrix

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Health History Points

A
  1. Previous History of Skin Disease
  2. Changes in Pigmentation
  3. Changes in moles
  4. Excessive Dryness or Moisture
  5. Pruitis
  6. Excessive Bruising
  7. Rash or Lesions
  8. Medications
  9. Hair Loss or Growth
  10. Change in Nails
  11. Environmental or Occupational
    Hazards
  12. Self-Care Behaviours
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Seborrhea

A

Oily skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Xerosis

A

Dry skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Physical Exam Points: Skin (5)

A
  1. Colour and Temperature of the Skin
  2. Moisture, Texture, Thickness
  3. Edema
  4. Mobility/ Turgor
  5. Lesions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Skin: Colour and Temperature (Physical Exam)

A

a. Pigmentation → normally consistent with ethnicity (note freckles, moles → new vs old)

b. Colour change - (new, acute, longterm) pallor, erythma, cyanosis, jaundice

c. temperature - skin should be warm bilaterally → use back of hand to assess

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Pallor

A

when the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the colour of connective tissue (white)
→ occurs with acute high
stress states such as anxiet or
fear because of the intense
peripheral vasoconstriction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Erythema

A

an intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries
→ expected with fever, local
inflammation, or emotional
reaction (blushing), often
accompanied by heat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Cyanosis

A

a blue discolouration that occurs with decreased perfusion or inadequately oxygenated blood
→ occurs with shock

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Jaundice

A

a yellow discolouration indicating rising amounts of bilirubin in the blood
→ first observed in the
junction of the hard and soft
palate in the mouth, and the
sclera

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Pigmentation Screening: ABCDE

A

A. Asymmetry
B. Borders (uneven)
C. Colour (two or more shades
abnormal)
D. Diameter (>0.6cm is
suspicious)
E. Evolution (change) rapidly in
size, shape, pigmentation,
symptoms or morphology

If 2+ criteria are considered abnormal, malignancy is suspected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Physical Exam: Skin Moisture

A

perspiration appears normally on the face, hands, azilla, and skinfolds in response to activity, a warm environment or anxiety

Abnormal Findings:
a. Diaphoresis - profuse perspiration
b. Dehydration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Diaphoresis

A

Profuse perspiration

17
Q

Dehydration (inspection)

A

look for dehydration in the mucous membranes of the mouth (should normally look smooth and moist with hydration)
- evident in decreased skin turgor

18
Q

Physical Exam: Skin Texture

A

normal skin feels smooth and firm with an even surface

19
Q

Skin Texture: Hyperthyroidism

A

skin feels smoother and softer, like velvet

Abnormal Findings:
a. Hyperthyroidism - smooth, soft
b. Hypothyroidism - dry, rough

20
Q

Skin Texture: Hypothyroidism

A

skin feels rough, dry, and flaky

21
Q

Physical Exam: Skin Thickness

A

the epidermis is uniformly thin over most of the body, although thicken callus areas are normal on the palms and soles

Abnormal Finding:
- Skin becomes very thin and shiny
with arterial insufficiency

22
Q

Physical Exam: Edema

A

fluid that accumulates in the intercellular spaces (not normally present)
→ Check for edema by imprinting
thumbs firmly against the ankle
malleolus or the tibia → normally
the skin regains a smoothness
immediately, however, if the
pressure leaves a dent, it is
indicative of edema

→ pitting edema graded from 1+ -
4+

23
Q

Physical Exam: Mobility + Turgor

A

Mobility: the skin’s ease of movement

Turgor: the ability of the skin to return to original position
- together, assess elasticity of the
skin
To assess: pinch a fold of skin on the anterior aspect of the chest under the clavicle and release
→ abnormal: skin remains peeked,
skin elasticity is low (turgor is low,
dehydration)
→ normal: returns to original
position in <2 seconds

24
Q

Physical Exam Points: Hair (4)

A
  1. Colour - consistent with age
  2. Texture - dull, coarse, brittle
  3. Distribution - appropriate for level
    of maturity (development) and
    gender
  4. Lesions - separate hair into sections
    to view the scalp → assess for
    cleanliness, presence of dandruff
    and lice
25
Q

Physical Exam Points: Nails (1)

A
  1. Shape + Contour - the nail surface is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded
    → Profile Sign - view the index finger
    at its profile and note the angle of
    the nail base (should be 160o)
    Abnormal Finding:
    • nail clubbing occurs at 180o+
26
Q

Documenting Lesions

A
  1. Colour - unipigmented,
    multipigmented
    - if exudate is present, note
    colour and odour
  2. Elevation - flat, raised, texture
  3. Pattern - grouping on surface of
    skin
  4. Size in cm - exact, use a flexible
    ruler
  5. Location and Distribution -
    generalized or localized?
27
Q

Pressure Ulcers

A

skin defect that extends into the dermis or deeper structure
- Occurs when excessive pressure is
placed on and distorts capillaries
→ occludes blood flow
- appears over bony prominence(s)
→ heels, coccyx, elbows, hips

Risk Factors: anything affecting ability to recognize/ perform ambulation
a. impaired mobility or sensory
perception
b. impaired LOC
c. poor nutrition - nutrients needed
for wounds to heal, if healing is
prolonged, bed rest might be too
d. shearing injury - the fragile sin of
the aging person, moisture from
incontinence/ sweating

28
Q

Braden Scale

A

Objective measurement to for skin risk assessment → likelihood of developing pressure ulcers

NSG2317 - health assessment (18 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions