Sensory/Integumentary System (Exam Two) Flashcards
(170 cards)
1
Q
What does the integumentary system consist of?
A
- Hair
- Nails
- Skin
2
Q
The skin is considered what?
A
An organ
3
Q
The skin is a barrier against what?
A
- Germs
- Pathogens
- Chemicals
4
Q
What are the two layers of the skin?
A
- Epidermis
- Dermis
5
Q
Which is the outermost layer of skin?
A
Epidermis
6
Q
What is the hypodermis composed of? What does it do?
A
- Made up of loose connective tissue and adipose tissue
- Insulates and acts as an energy reservoir
7
Q
What is the dermis composed of?
A
- Collagen fibers
- Elastin fibers
8
Q
What is the function of nose hair?
A
Filter from harmful substances
9
Q
What is the function of hair on the scalp?
A
Insulation
10
Q
What is the function of the eyelashes?
A
Protect the eye from dust and sweat
11
Q
Any break or laceration of the skin puts the patient at an increased risk for what?
A
- Infection
- Dehydration
12
Q
Describe the function of the five layers of the epidermis.
A
- Newest skin at the bottom layer
- Older skin at the top layer
- New layers are constantly replacing the old layers
- Old layers will slough off
13
Q
What is the skins function in relation to water?
A
- Keeps large amounts of water from exiting the body
- Keeps large amounts of water from entering the body
14
Q
What gives the skin and the hair its color?
A
Melanocytes
15
Q
What are three primary functions of the epithelium (skin)?
A
- Prevents too much water from entering/exiting the body
- Intact skin protects against infection
- Contains sensory receptors
16
Q
What role do blood vessels play in relation to the skin?
A
- Provide tissue nourishment
- Regulate temperature
17
Q
List the two types of sweat glands.
A
- Apocrine
- Eccrine
18
Q
Where are apocrine glands located?
A
- Axillary (armpit)
- Groin
19
Q
Where are eccrine glands located?
A
Rest of the body (where apocrine glands are not)
20
Q
How much water is lost through the eccrine glands per day? What type of loss is this?
A
- 500mL
- Insensible loss
21
Q
What are sebaceous glands responsible for? What type of substance is sebaceous glands?
A
- Prevents the hair and skin from drying out
- Oily
22
Q
Why does hair become gray and thin in the older adult population?
A
- Melanocytes die off
- Inactive hair follicles
23
Q
The skin of older adults is more prone to what?
A
- Skin breakdown
- Poor wound healing
24
Q
Slowed skin turgor is an indication of what?
A
Dehydration
25
Where should skin turgor be assessed on an older adult?
- Clavicle
- Shoulder
- Sternum
26
What is pallor? Where is pallor assessed?
- Pale skin
| - Mucus membranes, lips, nail beds
27
What is erythema?
Redness of the skin
28
What is jaundice? Where is jaundice assessed?
- Yellow or orange discoloration of skin
| - Oral mucosa, sclerae
29
What is cyanosis? Where is cyanosis assessed?
- Bluish discoloration of the skin
| - Nail beds, palms, soles of feet
30
Brown discoloration of the skin may result from what? Where is this most common?
- Chronic peripheral vascular disease
| - Lower legs
31
Skin inspection varies based on what?
Ethnicity or skin color
32
What ethnicity already has a bluish tint to the lips?
Mediterranean descent
33
What is a primary lesion?
Initial reaction to the disease process
34
What is a secondary lesion?
Changes that take place in primary lesion itself
35
Describe the characteristics of vesicles?
- Up to 1cm in diameter
- Blister-like appearance
- Contain serous fluid
36
List examples of vesicles?
- Poison ivy
- Shingles
- Chicken pox
37
Describe the characteristics of papules?
- 1cm in diameter
| - Solid, raised
38
List examples of papules?
- Mole
| - Wart
39
Describe the characteristics of a wheal?
- Insect bite appearance
- Round, elevated
- White in center
- Redness on outer edges
40
What are examples of a wheal?
- Hive
| - Mosquito bite
41
What is lichenification? What type of patients might suffer from lichenification?
- Thickening and hardening of the skin
| - Wheelchair bound patients
42
List the two vascular markings.
- Petechiae
| - Ecchymosis
43
What is petechiae? Where is petechiae best assessed in a patient with darker skin?
- Reddish purple hemorrhagic spots
| - Oral mucosa
44
What is ecchymosis?
Bruising
45
Bruises in different stages of healing may indicate what?
Abuse
46
Which portion of the hand is used to assess skin temperature?
Posterior surface
47
Describe 4+ pitting edema.
- Severe
- 8mm depression
- Can last more than 2 minutes
48
What does 0 indicate on the pitting edema scale?
No edema present
49
What is alopecia?
Hair loss
50
Excessive facial hair in females is associated with what disease?
PCOS
51
Hair thinning is associated with what disease?
- Hypothyroidism
| - Cushing's
52
What nail abnormality is associated with hypoxia?
Clubbing
53
What nail abnormality is associated with anemia?
Spoon nails
54
What nail abnormality is associated with fungal infections?
Thick nails
55
What is Beau's lines?
Transverse depressions of the nails
56
What are the three different types of skin biopsies?
- Punch
- Shave
- Excisional
57
What is Wood's lamp? What skin disease does it assess for?
- UV rays to detect fluorescent materials in skin/hair
| - Assess's for ringworm
58
Positive scratch test is indicated by what?
Wheal
59
The nurse should ensure which materials are in the room during a scratch test?
Crash cart
60
What is balneotherapy?
Therapeutic bath
61
Powders should be avoided in patients who have what type of problem?
Respiratory problems
62
What can a topical steroid medication cause?
Thinning of the skin
63
Why are newborns more prone to skin infections within the first week of life?
Due to more alkaline or basic skin integrity
64
Who is at a higher risk for skin cancer?
Caucasians
65
What are pressure ulcers?
Tissue anoxia due to pressure against the skin
66
What can cause pressure ulcers?
- Pressure
- Friction
- Shear
67
The nurse should never massage _____ _____.
Reddened areas
68
List prevention methods for pressure ulcers?
- Clean
- Dry
- Clean incontinence areas promptly
- Turn/reposition every two hours
- Provide adequate nutrition/hydration
69
What is included on the Braden Scale?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
70
What is considered a minimal risk score on the Braden Scale?
15-18
71
What is considered a moderate risk score on the Braden Scale?
13-14
72
What is considered a high risk score on the Braden Scale?
10-12
73
What is considered a very high risk score on the Braden Scale?
9 or below
74
How often should the Braden Assessment be conducted?
Once every shift
75
What does black skin indicate?
Necrosis
76
What does yellow skin indicate?
Infection or slough
77
What does red skin indicate?
Healing
78
What does pale pink skin indicate?
Poor blood supply or blood circulation
79
What is debridement?
Removal of dead tissue
80
List the different types of debridement.
- Mechanical
- Enzymatic
- Autolytic
- Surgical
81
What is mechanical debridement?
Scissors and forceps
82
What is enzymatic debridement?
Topical enzyme agent
83
What must be avoided with enzymatic debridement?
Healthy tissue
84
What is autolytic debridement?
- Dressing over wound
| - Natural enzymes break down eschar
85
Autolytic debridement cannot be used on what type of wounds?
Infected wounds
86
What is the nurses role regarding a therapy wound vac?
Management and troubleshooting of the machine
87
What should the nurse be cautious of in regard to wound care?
- Tape
| - Moisture
88
What is stage one of a pressure ulcer?
Skin is intact
89
What is stage two of a pressure ulcer?
Break in skin
90
What is stage three of a pressure ulcer?
Visible subcutaneous tissue
91
What is stage four of a pressure ulcer?
Visible muscle, tendon, or bone
92
What is considered an unstageable pressure ulcer?
- Covered with eschar or slough
| - Not visible to assess
93
What is a deep tissue injury? What might indicate a deep tissue injury?
- Damaged or dead tissue that does not have a break in the skin
- Indicated by a large bruise that does not have a cause
94
What is dermatitis?
Inflammatory skin disorder
95
What are the signs and symptoms of dermatitis?
- Itching
- Redness
- Skin lesions with varying borders/distribution patterns
96
Do pressure ulcers decrease in stages? How are they described?
- No
| - They are described by the diagnosed stage and stage of healing (i.e. stage 3 - healed/healing)
97
What is an example of atopic dermatitis?
Eczema
98
What are the signs and symptoms of eczema?
- Dry skin
- Pruritic (itchy)
- Exacerbation with serous fluid
- Remission and flare ups
99
What education should the nurse provide to a patient with eczema?
- Avoid fragrances
- Pat dry
- Avoid harsh soaps and added oils
- Soft, loose fitting clothes
- No fabric softener
100
What population is prone to eczema?
- Infants
| - Young children
101
What is contact dermatitis?
Direct contact with irritant or allergen
102
What are the two types of contact dermatitis?
- Immunological (allergen)
| - Non-immunological (irritant)
103
What are examples of immunological contact dermatitis?
- Nickel
- Poison ivy
- Poison oak
104
What are examples of non-immunological contact dermatitis?
- Diaper dermatitis/rash
| - Contact with feces, urine, harsh detergents, friction
105
What education should the nurse provide to the parents of an infant with recurrent diaper rash?
- Frequent diaper changes
- No harsh detergents
- Avoid wipes with chemicals
- Air out affected area
- Mild soaps
- Barrier creams
106
What is seborrheic dermatitis?
- Increased sebum production
| - Yeast overgrowth
107
Give an example of seborrheic dermatitis?
Cradle cap
108
What are the possible complications of dermatitis?
- Infection
| - Sepsis
109
When is infection likely to occur with deramtitis?
With scratching
110
List the steroid medications commonly used for dermatitis?
- Hydrocortisone
| - Methylprednisolone
111
What is psoriasis? How does psoriasis present on the skin?
- Proliferation of epidermal cells at a rapid rate
- Overgrowth of skin
- Scaling
112
What are the signs and symptoms of psoriasis?
- Silvery/White scales
- Papules
- Plaques
- Itching
113
What are the complications of psoriasis?
- Secondary infection
- Arthritis
- Nail changes
- Lymphadenopathy
114
What medications can be used in a patient with psoriasis?
- Topical corticosteroids
- Vitamin D
- Enbrel
- Methotrexate
115
When is methotrexate used for psoriasis patients?
Extreme cases
116
When can methotrexate not be used?
During pregnancy
117
What are the visual characteristics of impetigo?
Vesicles followed by honey colored crust
118
When is impetigo no longer contagious?
When lesions crust over
119
What is a furuncle?
- Small, tender boil
| - Occurs in one or more hair follicles
120
Where on the body are furuncle's common?
- Areas prone to perspiration
- Buttocks
- Axillae
121
What is a carbuncle?
- Abscess
| - Deeper than a furuncle
122
Where on the body are carbuncles located?
- Areas where skin is thick
- Back of neck
- Upper neck
- Buttocks
123
Furuncles and carbuncles are both caused by what kind of bacteria?
Staph
124
What are the two types of herpes simplex virus?
- HSV1 (fever blister)
| - HSV2 (genital herpes)
125
When does herpes reoccur?
With stress
126
What is herpes zoster?
- Acute inflammatory infection
| - Follows a nerve distribution
127
Give an example of herpes zoster?
Shingles
128
What causes herpes zoster?
Reactivation of chickenpox virus
129
Shingles are _____ to one general side or area.
Specific
130
What are the prevention methods for shingles?
- Varicella Vaccine (Varivax)
| - Zostavax
131
What is the primary nursing intervention for shingles?
Pain management
132
Ophthalmic herpes zoster affects which cranial nerve?
Cranial nerve V (5)
133
What medication can be administered for shingles? When is it most effective?
- Acyclovir
| - Within 72 hours of onset of rash
134
What medications might be associated with nerve pain?
- Anticonvulsants
| - Antidepressants
135
What causes tinea(s)?
Dermatophytes
136
What action should the nurse perform first in regards to cellulitis?
Draw a border around it
137
What is the most common cause of cellulitis?
Open wounds
138
Infections affecting the face may possibly spread to what other area?
Brain
139
What is acne vulgaris?
Increased sebum production
140
Where does acne vulgaris usually occur?
- Face
- Back
- Chest
- Shoulders
141
What are the two times of comedones?
- Open
| - Closed
142
What are open comedones?
Blackheads
143
What are closed comedones?
Whiteheads
144
What is pediculosis?
Lice
145
What are the signs and symptoms of pediculosis?
- Itching
- Papular rash
- Teardrop shaped masses (nits)
146
Pediculosides cannot be used on what ages?
Children under 2
147
What are scabies?
Mites that burrow into the skin
148
What are the signs and symptoms of scabies?
- Elevated short, wavy lines
- Itching
- Rash
149
What must be done in order for scabies to be diagnosed?
Must be viewed under microscope
150
How long might itching continue after treatment of scabies?
Two weeks
151
What is pemphigus?
- Autoimmune disorder
| - Fluid filled lesions on skin and mucous membranes
152
What are the triggers of pemphigus?
- Sun
- Certain drugs
- Certain food
153
Cancer arising from the basal cell layer is known as what?
Basal Cell Carcinoma
154
Cancer arising from the epidermis is known as what?
Squamous Cell Carcinoma
155
Cancer arising from the menalocytes is known as what? This cancer is highly what?
- Malignant Melanoma
| - Highly metastatic
156
What are the three different types of malignant melanoma?
- Lentigo
- Superficial spreading
- Nodular
157
Which type of malignant melanoma is the most common?
Superficial spreading
158
Describe nodular malignant melanoma.
- Occurs suddenly
- Blue-black//blue-gray/reddish blue in color
- Lesions are fragile and bleed easily
159
Which is the most dangerous form of malignant melanoma? Why?
- Nodular
| - Rapid growth and spreading
160
What is the most significant risk factor for developing skin cancer?
-Ultraviolet light/rays
161
How is skin cancer prevented?
- Limit exposure to UV rays
- Use sunscreen
- Wear protective clothing
- Report changes in moles
162
The nurse should educate the patient avoid the sunlight exposure during what time frame?
10AM to 4PM
163
What is a cyst?
- Saclike growth
| - Contains something inside
164
What is a keloid?
Overgrowth of tissue during scar formation
165
What is pigmented nevus?
Moles
166
What is verrucae?
- Warts
| - Viral infection by direct skin contact
167
Where do verrucae usually appear?
- Hands
- Fingers
- Feet
168
What is the cause of verrucae? When does it usually occur?
- Caused by HPV
| - Occurs during childhood or adolescents
169
What percent of warts will go away on their own?
2/3 of warts will go away on their own within two years
170
The nurse should educate the patient on what in regard to moles?
Report changes in moles
