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HEALTH ASSESSMENT - MIDTERMS > Integumentary System > Flashcards

Integumentary System Flashcards

1
Q

Most visible Organ observe by clinician in the initial survey or data gathering, thus supporting the general survey.

A

Skin

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2
Q

What are the 5 standard areas for a comprehensive skin assessment?

A

temperature, turgor, intact skin, color and moisture

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3
Q

What are the major components of the integumentary system?

A

skin, hair and nails

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4
Q

It is the largest Organ of the body.

A

Skin

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5
Q

How much does the skin weigh and surface area?

A

9lbs, about 15 to 20ft in adults

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6
Q

What is the structure of the skin?

A

Sratified

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7
Q

What are the layers of the skin?

A

Epidermal, dermal, subcutaneous layer

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8
Q

This gland of the dermal layer release secretions to lubricate the skin and regulate temperature.

A

Cutaneous glands

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9
Q

Hair and nails are composed of _______ cells

A

keratinized

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10
Q

These are hardened scleroprotein that is insoluble in water.

A

keratin/keratinized cells

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11
Q

Layer of the skin that produced keratinized cells which gives the epidermis it’s such protective qualities including hair, nails dental enamel and horny tissues

A

Stratum basale (germinativum)

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12
Q

Vitamin D is synthesized through.

A

7-dehydrocholsterol

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13
Q

It is the outermost portion of the skin were exposure to frition is greatest such as on the finger tips, palms and soles of the feet.

A

Epidermis

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14
Q

The epidermis regenerates from stem cells in the _______ layer that grow towards the ______

A

basale layer to corneum

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15
Q

True or false.

Epidermis is devoid of blood supply. It derives its nutrition from the underlying dermis.

A

True

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16
Q

What are the 5 layers of epidermis from top to bottom?

A

stratum corneum
stratum lucidum
stratum granulosum
stratum spinosum
stratum basale

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17
Q

Only found in the palms and soles.

A

stratum lucidum

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18
Q

Also called as germinativum

A

stratum basale

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19
Q

Also called as the horny layer

A

stratum corneum

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20
Q

What is the other term of shedding

A

Desquamation

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21
Q

How long does it take for a Complete turnover of cells to occur?

A

3 to 4 weeks

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22
Q

Is composed of columnar shape cells that rest on the basement membrane.

A

stratum basale

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23
Q

Layer where mitosis occurs and keratinized cells forms?

A

stratum basale

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24
Q

What layer creates pigment producing melanocyte?

A

stratum basale

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25
Q

Brown pigment.

A

melanin

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26
Q

Yellow-Orange pigment tones.

A

carotene

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27
Q

Red purple tones

A

vascular bed

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28
Q

This can be found inside the melanocytes That increase the melanin production when stimulated by sunlight and hormone.

A

melanosome

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29
Q

It filters violet light.

A

melanocytes(melanin)

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30
Q

True or false

more melanin results to darker skin colour.

A

True

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31
Q

Is the ability of the skin to reflect light?

A

Tyndall effect

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32
Q

Is a richly vascular connective tissue layer just below the epidermis.

A

dermis

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33
Q

another term for dermis

A

corium

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34
Q

What are the 2 types of fibres that consist the dermis?

A

collagen and elstic fibers

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35
Q

This fibre gives the skin its toughness and enables it to resist tearing

A

collagen

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36
Q

This fibre gives the skin its strength and elasticity.

A

elastic fibers

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37
Q

Connective tissue that stores approximately half of the body’s fat cells.

A

subcutaneous tissue

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38
Q

The other terms for subcutaneous tissue.

A

hypodermis or superficial fascia

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39
Q

It attach the skin to the underlying bones and cushions the body against trauma, insulates the body from heat loss and stores fat for energy.

A

Subcutaneous tissue/hypodermis/superfical fascia

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40
Q

Our bodies major source of tissue histamine and trigger the body’s reaction to allergens

A

mast cells

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41
Q

What are the different skin appendages?

A

hair, nails and glands

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42
Q

are glands formed in the stratum basale and pushed deep into the dermis.

A

Cutaneous glands

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43
Q

Release their secretions through ducts onto the skin surface.

A

Cutaneous glands

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44
Q

What is the other term for sweat glands.

A

sudoriferous glands

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45
Q

What are the 2 types of sweat glands?

A

eccrine and apocrine

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46
Q

These glands are more numerous and widely distributed they produce a clear perspiration mostly made up of water and salts which they release into the funnel shaped pores at the skin surface.

A

Eccrine glands

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47
Q

Found primarily in the axillary nipples navel and anogenital regions. Dormant until the onset of puberty and situations occurs during emotional stress and sexual stimulation.

A

Apocrine gland

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48
Q

What is the other term for apocrine gland?

A

odoriferous gland

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49
Q

They are distributed over most of the body except the palms of hands and soles of the feet.

A

Oil gland

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50
Q

Another term for oil gland.

A

Sebaceous gland

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51
Q

Most prevalent in the scalp forehead nose and chin.They produce sebum an oily secretion composed of fat and keratin that is usually released into her follicles.

A

Oil gland

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52
Q

It’s a thin flexible elongated fibre composed of dead keratin cells that grow out in a columnar fashion.

A

Hair

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53
Q

True or false.

Hair is derived from the epidermis but grows its roots into the dermis.

A

True

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54
Q

What are the two types of hair?

A

vellus hair and terminal hair

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55
Q

Fine, short strand grows over the entire body except for the margins of the lips the nipples, the palms of the hands, soles of the feet and part of the external genitals.

A

Vellus hair

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56
Q

It enhances tactile sensation and sensory perception.

A

vellus hair

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57
Q

Found on the eyebrows and scalp and usually darker, coarser and longer. Puberty hormones signal the growth of hair in the axilla will pubic region and legs of both sexes and on the face and chest of most males

A

terminal hair

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58
Q

Are thin, hard plates of keratinized epidermal cells that shield the distal ends of the fingers and toes.

A

NAils

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59
Q

Is the moon shaped cross and cold of the nail?

A

lunula

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60
Q

Is the fold of epidermal skin protecting their roots and sides of each nail.

A

cuticle/eponychium

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61
Q

The sense of touch is also known as ______, which is mediated by somatosensory system.

A

somatic sense or tactile perception

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62
Q

A network of neurons concerned with sensory Information from the skin.

A

exteroceptors

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63
Q

Joints andnd muscles.

A

Proprioceptors

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64
Q

internal organs

A

iteroceptors

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65
Q

Specialized receptors responsible for the sense of touch.

A

mechanoreceptors

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66
Q

What are the 4 main types of cutaneous mechanoreceptors?

A

Pacinian coruscles
Meissner’s corpuscles
Merkel’s discs
Krausse corpusclwe
Riffini endings

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67
Q

For deep pressure and vibrations.

A

Pacinain corpucles

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68
Q

For discriminative low-frequency vibrations.

A

Meissners’s corpuscles

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69
Q

For light touch.

A

Merkel’s discs

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70
Q

For cold Sensation.

A

Krausse

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71
Q

For warmth stretch movement and finger portion.

A

Riffini endings

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72
Q

Another term for corporis

A

ringworm

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73
Q

Other term for cruris

A

jock-itcch

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74
Q

Another term for pedis

A

Athlete’s foot

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75
Q

Another term for keratosis pilaris

A

chicken skin

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76
Q

What is the most common form of cancer in the philippines?

A

Basal cell carcinoma

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77
Q

Occurs less often and is the second most common form of skin cancer it affects dark skinned individuals and is seen in covered areas like the legs and feet.

A

Squamous cell cancer

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78
Q

Accounts for less than 2% of skin cancer. It is the most aggressive and deadliest.

A

Melanoma

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79
Q

True or false.

Tenting is normal in olde adults

A

True

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80
Q

What is creases?

A

skin folds

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81
Q

erythema

A

redness

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82
Q

ecchymosis

A

bruising

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83
Q

What light is the best for skin assessment?

A

Natural light or sunlight.

84
Q

True or false.

Dry skin does not necessarily indicate dehydration and maybe normal for dark skinned clients.

A

True

85
Q

True or false.

Tenting of the skin is a common finding in older adults.

A

True

86
Q

Pale color from anaemia or increase peripheral vascular resistance.

A

Pallor

87
Q

Bluish colour of the skin due to low oxygen saturation, low cardiac output or low vasoconstriction.

A

Cyanotic

88
Q

Yellow colour of the skin.

A

Jaundice

89
Q

What is the colour of the skin of patient with vitiligo and albinism

A

Absent

90
Q

What is the colour of the skin of patient with Addison disease and hemochromatosis?

A

Bronze/tanning

91
Q

What is the colour of the skin of patient with carbon monoxide poisoning

A

Cherry

92
Q

What is the colour of the skin of patient with arseni poisoning, cyanosis, hypoxemia, heart or lung disease, cold environment?

A

Dusky blue

93
Q

What is the colour of the skin of patient with anemia, vitiligo, albinism?

A

Pallor

94
Q

What is the colour of the skin of patient with leukemia, endocarditis, scarlet fever, viral; hemmorhagic fever, scurvy, and vasculitis?

A

Petechiae

95
Q

What is the colour of the skin of patient with erythema, fever, direct trauma, alcohol intake?

A

Pink/red

96
Q

What is the colour of the skin of patient with polycythemia, erythema, fungal infection?

A

Red

97
Q

What is the colour of the skin of patient with suntan, chloasma, systemic lupus erythematosus and scleroderma

A

Tan-brown

98
Q

What is the colour of the skin of patient with uremia, hemolysis, liver disease and carotenemia?

A

Yellow

99
Q

Patchy pale spots of pigment loss or denser spots of color appear. These skin discolorations are due to melanocyte clumping and are relatively small in size.

A

Lentigo senilis

100
Q

A catchall term that collectively describes any pathologic skin change or occurrence.

A

Lesions

101
Q

How to describe lesions using ABCDE?

A

Asymmetry
Border irregularity
Color variations
Diameter
Evolvement/enlargement

102
Q

True or False

Older clients may have skin lesions because of aging.

A

True

103
Q

waxy border; papule, red, central crater; metastasis is rare.

A

Basal cell carcinoma

104
Q

oozing, bleeding, crusting lesions; potentially metastatic; large tumors associated with a high risk of metastasis.

A

Squamous cell carcinoma

105
Q

irregular, circular, bordered lesion with hues of tan, black, or blue; rapid infiltration into tissue, highly metastatic

A

Melanoma

106
Q

It is the redness of the skin

A

Erythema

107
Q

Absent or missing nails

A

Anonychia

108
Q

Black or blue nails

A

Cyanotic

109
Q

Black nails

A

Trauma

110
Q

Very distal band or reddish-pink or brown covering less than 20% of nail.

A

Terry’s nails

111
Q

Very distal band or reddish-pink or brown covering greater than 20% to 60% of nail.

A

Lindsay’s nails

112
Q

Clubbing (180 degrees - >180 degrees) is a sign of _______

A

Chronic tissue hypoxia

113
Q

It is the spooning or concave nail.

A

Koilonychia

114
Q

It is the soft tissue infection around the nail

A

Paronychia

115
Q

It is the painless separation of nail from nailbed.

A

Onycholysis

116
Q

Ingrown nail

A

Onychocryptosis

117
Q

Deformed from nail biting

A

Onychophagy

118
Q

Are actual ridges and indentations in the nail plate

A

Beau’s line

119
Q

Are areas of hypopigmentation without palpable ridges

A

Muehrcke’s line

120
Q

Enumerate the primary skin lesions

A

Bulla
Cyst
Macule
Nodule
Papule
Plaque
Patch
Wheal
Tumor
Vesicle

121
Q

Enumerate the secondary skin lesions

A

Atrophy
Crust
Erosion
Fissure
Keloid
Lichenification
Ulcer
Scar/cicatrix
Scales

122
Q

Enumerate the vascular skin lesions

A

Hemangioma
Cherry angioma
Spider angioma
Ecchymosis
Hematoma
Petechiae
Telangiectasis
Vascular capillary, venous, lymphatic misinformation

123
Q

Are skin lesion that are circumscribed, flat and non-palpable

A

Macule
Patch

124
Q

Pigmented, non-palpable, small spot.

Examples: Freckles (ephelides) measles, petechiae

A

Macule

125
Q

Large macule greater than 1 cm in diameter

Examples: Vitiligo

A

Patch

126
Q

Are skin lesion that are palpable, elevated and solid mass

A

Papule
Plague
Nodule
Cyst
Tumor

127
Q

Circumscribed border up to 0.5 to 1cm

Examples: acne, moles and warts (verruca vulgaris)

A

Papule

128
Q

Elevated flat, surface larger than 0.5 to 1 cm

Examples: xanthelasma of the eyelids and psoriasis

A

Plague

129
Q

Larger than 0.5 cm often deeper and firmer than a papule

Example: lipoma, squamous cell carcinoma, fibroma

A

Nodule

130
Q

Elevated, encapsulated, fluid-filled or semi solid mass originating from the subcutaneous tissue or dermis, usually 1cm or larger.

Examples: sebaceous cyst and epidermoid cyst

A

Cyst

131
Q

Large nodule

Examples: Large neurofibroma and hemangioma

A

Tumor

132
Q

Are skin lesions that are circumscribed superficial elevation of the skin.

A

Vesicle
Bulla
Wheal
Pustule

133
Q

Up to 0.5cm, elevated, filled with serous fluid

Example: poison ivy, chicken pox and herpes simplex

A

Vesicle

134
Q

Greater than 0.5 to 2cm, filled with serous fluid

Examples: 2nd degree burn, friction blisters, bullous pemphigoid

A

Bulla

135
Q

Elevation, often reddish with irregular border caused by diffused fluid in tissue rather than the free fluid in cavity, as in vesicles. They are raised firm lesions with intense localized skin edema varying size and shape and transient occurrence. It disappears in hours.

Examples: insect bites and hives

A

Wheal

136
Q

Filled with pus.

Examples: acne, impetigo and carbuncle

A

Pustule

137
Q

Are skin lesions due to loss of skin surface

A

Erosion
Ulcer
Fissure

138
Q

Cause a moist, shallow depression. They heal without scarring. Loss of superficial epidermis. leaving a moist ar3ea that does not bleed.

Example: skin surface after ruptured vesicle and scratch marks

A

Erosion

139
Q

Irregularly shaped extending into the dermis or subcutaneous tissue. A deeper loss of surface that may bleed and scar

Examples: syphilitic chancre, ulcer of venous sufficiency and stasis ulcer

A

Ulcer

140
Q

A linear crack.

Examples: athlete’s foot

A

Fissure

141
Q

Skin lesion that are materials on skin surface

A

Scar
Keloid
Lichenification
Scales
Crust

142
Q

The dried residue of serum, pus, or blood

Examples: scab following abrasion; impetigo

A

Crust

143
Q

Shedding flakes of greasy, keratinized skin tissue. Color may be white, gray or silver. Texture may vary from fine to thick. It could also be thin flake or exfoliated epidermis.

Examples: dry skin, dandruff and psoriasis

A

Scales

144
Q

Is a rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing.

Examples: chronic atopic dermatitis

A

Lichenification

145
Q

a flat irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or purple; older scars may be silvery or white

Examples: healed surgical wound or injury and healed acne

A

Scar

146
Q

An elevated irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing.

Examples after ear piercing or surgery

A

Keloid

147
Q

This is caused by fires, steam, hot liquids, electrical and chemical sources.

A

Burns

148
Q

Superficial thickness

A

First-degree burn

149
Q

The epidermis is injured or destroyed; there may be some damage to the dermis; hair follicles and sweat glands are intact; the skin is red and dry; painful, no blisters.

A

First-degree burn

150
Q

Partial thickness, superficial or deep

A

Second-degree burn

151
Q

The epidermis and upper layers of the dermis are destroyed; the deeper dermis is injured; hair follicles, sweat glands, and nerve endings are intact; the skin is red and blistery with exudates; painful blisters are present.

A

Second-degree burn

152
Q

Full thickness

A

Third-degree burn

153
Q

The epidermis and dermis are destroyed; subcutaneous tissue may be injured; hair follicles, sweat glands, and nerve endings are destroyed; the skin is white, red, black, tan, or brown with a leathery-looking appearance; painless because nerve endings are destroyed.

A

Third-degree burn

154
Q

Full thickness

A

Fourth-degree burn

155
Q

The epidermis and dermis are destroyed; subcutaneous, muscle, and bone may be injured; the skin is white, red, black, tan, or brown with exposed and damaged subcutaneous tissue, muscle, or bone; painless.

A

Fourth-degree burn

156
Q

What is the most painful degree of burn?

A

2nd degree burn

157
Q

Scale used to assess the risk for pressure ulcer in adult patients

A

Norton scale

158
Q

Scale used for predicting pressure sore risk

A

Braden Scale

159
Q

Pressure ulcer can occur as a complication of _________

A

immobility

160
Q

What is the major cause of pressure ulcers?

A

External pressure that occludes the blood vessels

161
Q

Is a horizontal force that occurs when the skin and underlying subcutaneous tissues are pulled tight and over stretched.

A

Shear

162
Q

Is a non-blanchable erythema of intact skin, the heralding lesion of skin ulceration. The epidermis remains intact. Indicators include discoloration or darkened skin, warmth, edema, induration, or hardness. For persons with darkly pigmented intact skin, assess for erythema and/or inflammation with localized changes in skin temperature. Indicator for more frequent repositioning and the use of a pressure-reducing device.

A

Stage 1

163
Q

Shows partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

A

Stage 2

164
Q

Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer is a deep crater with or without undermining of adjacent tissue.

A

Stage 3

165
Q

The final stage, is full-thickness skin loss with extensive destruction, tissue necrosis, or damage to the muscle, bone, or supporting structures (e.g., tendon or joint capsule).

A

Stage 4

166
Q

Wound Assessment Checklist: pressure ulcer documentation includes the following:

A

Anatomical Location
Size
Dressings
Drainage
Undermining/Tunnelling
Character of the wound
Stage
Pressure-reducing/relieving device

167
Q

Thin, bright red drainage or discharge color

A

Sanguineous/Blood

168
Q

Thin, watery, pale red to pink drainage or discharge color

A

Serosanguineous

169
Q

Thin, water, clear drainage or discharge color

A

Serous

170
Q

Thin or thick, opaque tan to yellow drainage or discharge color

A

Purulent

171
Q

Thick, opaque yellow too green with an offensive odor drainage or discharge color

A

Foul purulent

172
Q

Growth of small blood vessels and connective tissue to fill full-thickness wounds.

A

Granulation

173
Q

Process of epidermal resurfacing and appears pink or red skin

A

Epithelialization

174
Q

Pain: Intermittent claudication to sharp; feeling of cold; unrelenting, constant

A

Arterial Insufficiency

175
Q

Pulses: Diminished or absent

A

Arterial Insufficiency

176
Q

Skin characteristics: Dependent rubor

Elevation pallor of foot

Dry, shiny skin

Cool-to-cold temperature

Loss of hair toes and dorsum of the foot

Nails thick and ridged

A

Arterial Insufficiency

177
Q

Location: Tips of toes, toe webs, heel, or other pressure areas if confined to bed

A

Arterial Insufficiency

178
Q

Pain: Very painful

A

Arterial Insufficiency

179
Q

Depth of ulcer: Deep, often involving joint space

A

Arterial Insufficiency

180
Q

Shape: Circular

A

Arterial Insufficiency

181
Q

Ulcer base: Pale black to dry and gangrene

A

Arterial Insufficiency

182
Q

Leg edema: Minimal unless extremely kept in a dependent position constantly to relieve pain

A

Arterial Insufficiency

183
Q

Pain: Aching, tiredness, fullness, cramping. Chronic pain; prolonged sitting standing; increases at the end of the day.

A

Venous Insufficiency

184
Q

Pulses: Present but may be difficult to palpate through edema

A

Venous Insufficiency

185
Q

Skin characteristics:

Pigmentation in Gaitor (area or medial and arterial malleolus)

Skin thickened and tough.

May be reddish blue in color.

Frequently associated with dermatitis

A

Venous Insufficiency

186
Q

Location: Medial malleolus or anterior tibial areas

A

Venous Insufficiency

187
Q

Pain: If superficial, minimal pain, but may be very painful

A

Venous Insufficiency

188
Q

Depth of ulcer: Superficial

A

Venous Insufficiency

189
Q

Shape: Irregular border

A

Venous Insufficiency

190
Q

Ulcer base: Granulation tissue-beefy red to yellow fibrinous in chronic long-term ulcer

A

Venous Insufficiency

191
Q

Leg edema: Moderate to severe

A

Venous Insufficiency

192
Q

Skin test for chicken pox and herpes

A

Tzanck smear

193
Q

Where to test for skin turgor in infants?

A

over the abdomen

194
Q

What is the term for the combination of turgor and mobility?

A

Elasticity

195
Q

What is the term for the resiliency, or the skin’s ability to return to its normal position and shape?

A

Turgor

196
Q

True or False

Pinching the skin is not accurate for older clients due to atrophy.

A

True

197
Q

True or False

Skin turgor is not a good test to assess dehydration status of older clients.

A

True

198
Q

True or False

As people age, hair feels coarser and drier

A

True

199
Q

True or False

Dark-skinned newborns have more lanugo than lighter-skinned newborns

A

True

200
Q

What is seborrhea?

A

Dandruff

201
Q

Is a test done on the nail beds to monitor perfusion, the amount of blood flow to the tissue

A

Test capillary refill

202
Q

Where to blanch to test capillary refill of neonates and infants?

A

Dorsum of the foot or palmar surface

203
Q

How many seconds should the color returns in test for capillary refill to be considered as normal?

A

1-2 seconds

204
Q

It is a useful test of hydration status in pediatric clients.

A

Test capillary refill

205
Q

Where is the best place to test for capillary refill in children?

A

Forearm or over the patella.

206
Q
A

HEALTH ASSESSMENT - MIDTERMS (2 decks)

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