Integumentary Assessment Flashcards
(45 cards)
1
Q
Integumentary System
A
- Skin, nails, hair & sweat glands
- Reflection of hydration, nutrition & emotional status
- Skin is 1st line of defence against environmental threats
2
Q
Risk Factors of Integumentary Conditions
A
- Nutrition status (vitamin/mineral deficiency)
- Immobility (pressure, forces, friction)
- UV exposure (natural & artificial)
- Skin entry infectious diseases (manifestation/immunization)
3
Q
Skin Health
A
- Benign mole investigation
- Skin self-examination
- UV exposure (seek, slip, slap, slop)
- Radiation (high risk for malignant skin cancers)
- Vitamin D & tanning beds
4
Q
Skin Layers
A
- Epidermis
- Dermis
- Subcutaneous (hypodermis)
5
Q
Melanoma Skin Cancer
A
- Most dangerous skin cancer
- Spreads in body
- Less common
6
Q
ABCDE of Melanoma
A
- Asymmetry (shape difference on sides)
- Border (visible edge is irregular, ragged, imprecise)
- Colour (colour variation within legion)
- Diameter (growth is normal <6mm)
- Evolution (change in color, shape size & symptoms itching, tenderness, swelling)
7
Q
Subjective Data Collection for Integumentary Assessment
A
- Family history (melanoma history = higher risk)
- Past history
- Medications (allergies)
- Lifestyle (occupational, personal behaviors)
8
Q
Specific Questions for Integumentary Assessment
A
- OLDCARTSS
- Painful or itchy
- Progression
- Associated symptoms (fever, malaise)
9
Q
Cyanosis
A
- Blue tint
- Lack of oxygen
- Around nails/mouth
10
Q
Pallor
A
- Paleness
- Decreased hemoglobin/anemia
11
Q
Jaundice
A
- Yellowing of skin
- Underlying liver disorder
12
Q
Erythema
A
- redness
13
Q
Edema
A
- swelling on skin
14
Q
Types of Primary Legions
A
- Vesicle
- Pustule
- Cyst
- Macule
- Papule
- Wheal
15
Q
Configuration of Legions
A
- Location of legions
- Distribution (localized, regional, generalized)
- Primary (initially appearing) or secondary (resulting from change to primary)
- Shape & size
- Margins/borders
- Morphology (papule, plaque, pustule, bulla, macule)
- Colour/pigmentation
- Texture/consistency
16
Q
Papule Legion
A
- Raised legion
- <1cm
- Wart, insect bite
17
Q
Plaque Legion
A
- slightly raised
18
Q
Bulla Legion
A
- contains fluid
19
Q
Macule Legion
A
- Flat
- <1cm
- Freckles, tattoos
20
Q
Pustule Legion
A
- Contains pus
- Generally raised
- Can be various sizes
- Surface of skin
- ACNE
21
Q
Vesicle Legion
A
- Fluid filled blister
- Various sizes depending on stage
- Surface of skin
- HERPES/CHICKEN POX
22
Q
Cyst Legion
A
- Distinct walled off legion
- Underneath skin
- Fluid filled/semisolid
- Could contain pus, cells, infection (palpation will confirm pus)
23
Q
Wheal Legion
A
- Slightly raised (less than papule)
- Flesh coloured/erythematous
- Range between papules/plaques
- Varies in shape & size
24
Q
Types of Secondary Legions
A
- Scar
- Ulcer
- Excoriation
25
Scar Legion
- Overhealed skin
- Raised
26
Ulcer
- Loss of skin surface
- Extend into dermis, subcutaneous, fascia, muscle, bone
27
Palpation of Legion
- Access skin texture, moisture, temperature
- Access skin turgor for hydration status (below clavicle)
- Check lesions for tenderness, mobility & consistency
- Hair & nails for brittleness
- Presence of infection or drainage requires gloves
28
Types of Rashes
- Eczema
- Fungal infection
- Psoriasis
- Cradle cap
- Tinea Capitis
- Trichotillomania
- Subungual Hematoma
29
Eczema
- Dryness
- Allergies/asthma
30
Fungal Infection
- Well circumscribed legion
- With erythematous borders
31
Psoriasis
- Causes plaques & legions on skin
32
Cradle Cap
- Yellowing/crusting
- Alleviates over time
33
Trichotillomania
- Mental health condition
- Pulling out hair
- No follicle breakage (grows back)
34
Subungual Hematoma
- Blood collects under toe(s)
- Some sort of trauma inducement
35
Pregnant Women Skin Conditions
- Melasma, facial darkening related to hormonal changes (reversible)
- Linea nigra, pregnancy line related to hormonal changes (resolve few months after pregnancy)
36
Newborn/Infant Skin Conditions
- Vernix, white substance covers baby in uterus
- Stork bites, vascular collection of tissue (resolves in 1-2 years)
- Mongolian spots, blemish bruise mark around sacrum
37
Older Adult Skin Conditions
- Sun damage to skin
- Basal cell carcinoma, raised central ulceration
- Actinic keratosis, precursor to squamous cell carcinoma (untreated)
- Seborrheic keratosis, sun damage (non-cancerous growth on skin)
38
Pressure Ulcer Assessment
- Stages 1-4
- Braden scale risk assessment
- Repositioning every 2 hours
- Break in skin = risk of infection
- Can become septic
39
Pressure Ulcer Stage 1
- Intact skin
- Non-blanchable redness of localized area (over bone)
- May be painful, firm, soft, warm/cold compared to adjacent tissue
40
Pressure Ulcer Stage 2
- Partial thickness of dermis
- Shallow opening with red/pink wound bed
- Shiny/dry
- No slough/bruising
41
Pressure Ulcer Stage 3
- Full thickness tissue loss
- Visible fat
- Slough present, not obscuring depth of tissue loss
- May be undermining & tunneling
42
Pressure Ulcer Stage 4
- Full thickness tissue loss
- Exposed bone, tendon, muscle
- Visible/directly palpable
- Slough/eschar present
- Undermining & tunneling
43
Prompt Evaluations & Interventions of Skin
- Acute dehydration
- Cyanosis
- Impaired skin integrity
44
Acute Trauma & Burns Stages
- Intact skin
- Partial thickness
- Full thickness
- Full thickness with exposure (bone/tendon)
45
Rule of 9's
- Used for 2nd degree (partial thickness) & 3rd degree (full thickness)
- Arms each 9%
- Head & neck 9%
- Front of body (chest & torso) 18%
- Legs each 18%
- Back of body 18%
- Genitalia 1%
