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Health Assessment > Ch.11 Integumentary/Skin Assessment > Flashcards

Ch.11 Integumentary/Skin Assessment Flashcards

1
Q

melanoma detection

A

ACBDE
a: asymmetry
b: border irregularity
c: color
d: diameter of more than 6mm
e: evolution of lesion over time

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2
Q

what are common integumentary symptoms?

A
  • pruritus: itching
  • rash ( multiple lesions )
  • single lesion or wound
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3
Q

abnormal integumentary findings

A
  • skin:
    ➡️ pigmentation changes
    ➡️ lesions
    ➡️ infections
    ➡️ growths or tumors
    ➡️ wounds
    ➡️ skin breakdown
  • nails:
    ➡️ color, thickness & angle ( clubbing )
  • hair:
    ➡️ color, consistency & distribution
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4
Q

what is the skin assessment of blanching

A

training to assess skin breakdown that incudes testing the skin’s blanch response to light finger pressure ( ex. assessing for stage I pressure ulcer, apply light pressure to the skin to note blanching ( whitening )

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5
Q

erythema

A

redness caused by irritation or stress
( in darker skin, redness may not be visible )

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6
Q

hyperpigmentation

A

increased pigmentation

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7
Q

hypopigmentation

A

reduced pigmentation

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8
Q

how many secs to check on a capillary refill?

A

5 seconds

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9
Q

how many secs to check the color back from the finger on the capillary refill?

A

2 seconds

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10
Q

cyanosis

A

5g/dL of unoxygenated hemoglobin in the arterial blood
➡️ central cyanosis ( cyanosis of the lips, mucous membranes, & tongue ) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels

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11
Q

cyanosis in different skin tones

A
  • light-skinned: cyanosis presents as dark bluish tint to skin & mucous membranes
  • dark-skinned: cyanosis presents as gray or whitish skin around the mouth; conjunctivae may appear gray or bluish
  • in yellowish skin: cyanosis presents as grayish-greenish skin tone
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12
Q

wound healing phases

A
  • inflammatory phase: begins within 30 minutes & last 2-3 days
  • proliferative phase: begins at the end of the inflammatory phase may last up to 4 weeks
  • remodeling phase: begins at the end of the proliferative phase & may last as long as 2 years
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13
Q

braden scale

A
  • scoring scale for predicting pressure ulcer risk
  • braden scores patients from 1-4 in each of six subscales: sensory perception, moisture, activity, mobility, nutrition, & frictions ( 14-18: high risk )
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14
Q

stage I pressure injury

A

intact skin with non-blanchable redness of a localised area usually over bony prominences

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15
Q

stage II pressure injury

A

partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough

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16
Q

stage III pressure injury

A

full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed

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17
Q

stage IV pressure injury

A

full thickness tissue loss with exposed bone, tendon or muscle

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18
Q

unstageable pressure injury

A

full thickness tissue loss in which the ulcer base is covered by slough ( yellow, tan, gray, green or brown ) and/or eschar ( tan, brown, or black ) in the wound bed

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19
Q

percentage of burn on head

A

9%

20
Q

percentage of burn of anterior & posterior

A

both 18%: 36%

21
Q

percentage of burn on humerus

A

9%

22
Q

percentage of burn on groin

A

1%

23
Q

percentage of burn on legs

A

18%

24
Q

grade 1 edema

A

0-2 mm indentation; rebounds immediately

25
Q

grade 2 edema

A

3-4 mm indentation; rebounds in <15 seconds

26
Q

grade 3 edema

A

5-6 mm indentation
up to 30 seconds to rebound

27
Q

grade 4 edema

A

8 mm indentation; > 20 seconds to rebound

28
Q

lifespan considerations: older adults

A
  • skin ages, loss of elastin, collagen, & subcutaneous fat
  • decreased skin turgor ( elasticity of the skin )
  • decreased melanin production
  • thin brittle nails
29
Q

urgent assessment

A
  • acute dehydration, or cyanosis
  • acute traumas that may include burns, large wounds
  • not usually emergent
    ➡️ small lacerations
    ➡️ suspicious lesions
    ➡️ rash & fevers
30
Q

subjective data collection

A
  • assess the patient for potential risk factors
    ➡️ overall health
    ➡️ nutritional status
    ➡️ medications
  • health promotion & risk assessment
    ➡️ self skin assessment ( SSE )
    ➡️ patient education
31
Q

photo-reactions

A

medications:
- anitmicrobials
- psychotropic & other psychiatric agents
- cardiovascular agents
- herbals & topical
- antihistamines
- disease-modifying agents
- hypoglycemic
- topical agents
- nonsteroidal anti-inflammatory drugs

32
Q

objective data collection

A
  • performed in a head to toe format
    ➡️ general skin assessment
    ➡️ assess the skin with inspection of each body area
  • color, temperature, moisture, turgor, texture
  • assess & describe; wounds, lesions, rashes, hematomas
33
Q

skin color basics

A
  • pallor ( anemia )
  • cyanosis ( hypoxemia )
  • redness ( burns )
  • color changes ( pressure ulcers )
34
Q

review question #1: the nurse is admitting a 75 year old male with a 50 year history of smoking one pack of cigarettes per day. among the patient’s concerns is his chronic shortness of breath. one nail finding that demonstrates chronic hypoxia is?

A

clubbing

35
Q

review question #2: all of the following skin lesions may be papular expect?

A

herpes zoster

36
Q

review question #3: the ABCDEs of melanoma identification do not include?

A

birthmark ( correct term is border irregularity )

37
Q

review question #4: a nurse observes a skin lesion with well-defined borders on the upper left thigh. it is 1.5 cm in diameter, flat, hypopigmented, & nonpalpable. what is the correct terminology for this lesion?

A

patch

38
Q

review question #5: when assessing hydration, the nurse will?

A

pinch a fold of skin on the medial aspect of the forearm & observe for recoil to normal

39
Q

review question #6: a fair skinned, blonde, 18 year old female is at the clinic for a skin examination. she reports that she always turns red within 10 minutes of going outside. she is planning a trip to mexico & wants to avoid getting sunburned. which of the following would be included in the teaching? ( select all that apply )

A
  • excessive exposure to UVA & UVB rays increases risk of sunburn & skin cancer
  • apply sunscreen or sunblock at least 15-30 minutes before sun exposure
  • avoid sun exposure between 10 a.m.-4 p.m. to reduce UVA & UVB exposure
40
Q

review question #7: a patient presents to the clinic with erythematous vesicles on the face & chest. some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. which of the following infectious illnesses does the nurse suspect?

A

varicella

41
Q

review question #8: a 24 year old patient reports an itchy red rash under their breasts/chest. examination reveals large, reddened, moist patches under both breasts/chest in the skin folds. several smaller, raised, red lesions surround the edges of the larger patch. what is the correct terminology for the distribution pattern of these smaller lesions?

A

satellite

42
Q

review question #9: a 22 year old patient present to the clinic with a large firm mass on their left earlobe. they had their ears pierced approximately 6 weeks ago. the mass began as a small bump & progressively enlarged to its current size of approximately 2.5 cm ( 1 inch ) in diameter. it is not tender, reddened, or seeping any drainage. what is the term used to describe this secondary skin lesion?

A

keloid

43
Q

review question #10: an 83 year old female is undergoing a routine physical examination. which of the following assessment findings would the nurse consider an expected age-related variation?

A

thinning of the skin

44
Q

review question #11: a patient has several red, inflamed, superificial, palpable lesions containing a thickened yellowish substance. how would the nurse document this lesion?

A

pustule

45
Q
A

Health Assessment (4 decks)

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