Integument & Quick Neuro Flashcards
(32 cards)
What are the components of a quick neuro check?
LOC Orientation - to person, place, time of day Communication - Can they follow a conversation, appropriate responses, speech clear/articulate Motor response - moving all limbs appropriately
Identify and define the 5 levels of consciousness
1) Alert (awake and responsive)
2) Lethargic (tired/drowsy) – still able to answer questions but a bit fuzzy
3) Obtunded - difficult to arouse, one word answers, mumbling
4) Stupor (spontaneously unconscious)
- Sleep like state, little/no spont. activity, respond only with grimacing, withdraw to pain
5) Coma (deep state of prolonged unconsciousness)
Unable to arouse, no response to stimuli (including painful ones)
- May have reflexes but to purposeful movement
When is a good time to do an integument assessment?
During a head-to-toe check or bedbath
Name the 3 layers of skin from superficial to deep.
Epidermis -> dermis -> subcutaneous
Identify and define the two layers of the epidermis
Basal Cell Layer – deepest layer of epidermis
- contains keratin (waterproof) & melanin (colour)
Horny Cell Layer – most superficial skin layer facing outside
- Has mainly dead skin cells
T or F: the epidermis is avascular
True
Nerves, blood & lymphatic vessels, hair follicle, and glands exist in the ______ layer of the skin
Dermis
The dermis consists mainly of ______
collagen
What are the functions of the subcutaneous layer
temperature control
cushion for underlying structures
gives skin mobility / ability to move across underlying structures
Define Vellus vs. Terminal hair (epidermal appendages)
Vellus – fine, faint hair that covers most of the body
Terminal – darker thicker hair that grows on scalp, eyebrows, axillae, pubic area, (face & chest on men)
_____ are muscles that surround the hair follicle and contract to elevate hair (goosebumps) during cold or emotional states
Arrector Pili
Name 5/9 the functions of the skin
1) Protection
- From injury, infection, UV radiation, fluid balance
2) Guards the body
- Stops invasion of microorganisms and loss of water/electrolytes
3) Perception
- Sensory organ (touch, pain, temp, pressure)
4) Temperature regulation
- Sweating (cooling) & subcutaneous insulation
5) Identification
- self-image and identifying with other people, fingerprints
6) Communication
- Facial expressions, blushing (vascular mechanism) -> conveying emotion
7) Wound repair
- Cell replacement of surface wounds
8) Absorption and excretion (absorb UV light, excrete some waste)
9) Production of vitamin D
- skin converts cholesterol to vit D via UV light
What is the fxn of sebaceous glands and where are they located?
Produce sebum (oily) which gets secreted through hair follicles and slows water loss from surface of skin (keeps skin hydrated/lubricated) Everywhere except palms and soles
What are the 2 types of sweat glands and where are they located?
1) Eccrine glands –open directly onto the skin surface and produce sweat aka dilute saline solution (important for temp regulation) – not present in infants until 2 months
2) Apocrine glands - produce a thick, milky secretion and open into the hair follicles
- Located in axillae, anogenital area, nipples, and navel
- Flora + aprocrine glands secretion = musky odour
- Become active during puberty
What are the 4 epidermal appendages
hair
sebaceous glands
sweat glands
nails
What are some developmental considerations for infants in an integument assessment
- Lanugo = fine downy hair of the newborn infant (all over body) NOTE: DIFF THAN VELLUS HAIR
- Vernix (aka vernix caseosa) = thick, white, lipity substance made up of sebum and shed epithelial cells (white stuff babies are covered in when they are born)
- Milia = acne bumps, on face and nose
- Eccrine glands (sweat glands) not functional until 2 months of age
- Subcutaneous layer insufficient until 6 months (newborns not good at thermoregulating)
What are some developmental considerations for adolescents in an integument assessment
Increased secretion from the apocrine glands
- Become active during puberty, body odour starts
- Secretion occurs with emotional and sexual stimulation
Sebaceous glands become more active – skin gets oily
Subcutaneous fat deposits increase – especially in the pelvic area of females
What are some developmental considerations for pregnant women in an integument assessment
- changing hormone levels = increased pigmentation around nipples, vulva, linea nigra, chloasma
- striae gravidum
What are some developmental considerations for older adults in an integument assessment
Decreased skin elasticity, subcutaneous fat & muscle tone -> hanging quality of muscle + wrinkles
Sweat and sebaceous glands decrease in number and function
Decreased melanocytes (causes hair to turn grey)
- Hair distribution changes (can occur in mid 30s)
- W-shaped balding in men
- axillary and pubic hair decreases
Women may have bristly facial hair
Components of a subjective integument assessment
Hx of skin disease change in pigmentation excessive dryness or moisture pruritus (itching) excessive bruising rash or lesions enviro or occupational hazards change in a mole hair loss change in nails self-care behaviours medications
Components of an objective skin assessment (inspect and palpate)
Colour - pallor, erythema, cyanosis, jaundice, pigmentations (ABCDE)
Temperature - normal, hypo/hyperthermia
Moisture - diaphoretic (profuse sweating), dehydration (look at mucous membranes)
Texture - too smooth (hyperthyroidism), too rough (hypothyroidism)
Thickness
Edema
Mobility and Turgor
Vascularity or bruising
Lesions
Describe the edema 4 point scale
1+= mild pitting, slight indentation, no perceptible swelling 2+= moderate pitting, indentation subsides rapidly 3+= deep pitting, indentation remains for a short time, limb looks swollen 4+= very deep pitting, indentation lasts a long time, limb is very swollen
Poor turgor aka “tenting” is a sign of _______
severe dehydration or weight loss
Sclerodema is a sign of ______
“hard skin”
decreased mobility
