skin and tissue integrity Flashcards
(54 cards)
skin color is derived from what three sources
Melanin—brown pigment
Carotene—yellow-orange pigment
Red purple tones in the underlying vascular bed
all individuals have what difference with skin color
All individuals have varying amounts (red, yellow, and brown).
With the relative proportion affecting prevailing color
Also modified by thickness of skin and presence of edema
the skin is and has what
Skin is washable, waterproof, & rugged -> has protective & adaptive properties
the types of functions of skin
protection
prevents penetration
perception
fluid balance
temperature regulation
identification
communication
wound repair
absorption and excretion
production of vitamin D
medications - tetracycline
- given a lot for people with acne
- makes the skin more sensitive and prone to sunburns
subjective data health history questions
Past history of skin disease, allergies, hives, psoriasis, or eczema
Change in pigmentation
Change in mole (size or color)
Excessive dryness or moisture
Pruritus
Excessive bruising
Rash or lesions
Environmental or occupational hazards
inspect and palpate the skin - color
Color
General pigmentation, freckles, moles, birthmarks
Widespread color change
* Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow)
* Note if color change transient or due to pathology
inspect and palpate the skin - temperature
Use backs of hands to palpate person
Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status.
Hands and feet may be slightly cooler in a cool environment.
* Hypothermia
* Hyperthermia
inspect and palpate the skin - what to check for in moisture
diaphoresis
dehydration
inspect and palpate the skin - lesions
if any are present, note the following:
Color
Elevation flat, raised or pedunculated
Pattern or shape grouping or distinctness
Size measure in centimeters
Location and distribution on body
Any exudate: note color and odor
Use a dermatoscope for closer inspection
ABCDEF skin assessment (exam)
- A: asymmetry
- B: border irregularity
- C: color variations
- D: diameter greater than 6 mm
- E: elevation or evolution
- F: funny looking—“ugly duckling” —different from others
what should you do for the ABCDEF skin assessment
Promoting health and self-care
Teach skin self-examination using ABCDEF rule to detect suspicious lesions
developmental competence: infant skin presentations
Skin color—general pigmentation
Mongolian spot
Café-au-lait spot
Skin color change
Harlequin color change
Erythema toxicum
Temporary cyanotic conditions
Acrocyanosis
Cutis marmorata
Physiologic jaundice
Carotenemia
Moisture, texture, thickness, mobility and turgor
Vascularity or bruising—nevus simplex
Hair and nails—lanugo and presence of cyanosis in newborn
developmental competence: life-cycle presentations - adolescents
Adolescent
Acne
Open and closed comedones
developmental competence: life-cycle presentations - pregnancy
Striae (stretch marks)
Linea nigra
Chloasma
Vascular spiders
developmental competence: life-cycle presentations - aging for skin color and presentations (exam)
- Solar lentigines (liver spots) -> dark spots, often from sun exposure
- Keratoses -> seborrheic or actinic
developmental competence: life-cycle presentations - aging for moisture (exam)
xerosis - dry skin
developmental competence: life-cycle presentations - aging for texture
- Skin tags or acrochordons
- Sebaceous hyperplasia
developmental competence: life-cycle presentations - aging for thickness
Thin parchment as subcutaneous fat decreases
developmental competence: life-cycle presentations - miscellaneous
Decreased mobility and turgor
Decreased hair growth, nail growth, and brittle nails
define xerosis
known as dry skin
- excessive dry skin
detecting color changes in light and dark skin
Be aware of normal variations for the following variables:
Pallor
Cyanosis
Erythema -> redness and swelling of the skin
Jaundice -> often shows liver damage
common shapes and configurations - annular or circular
begins in the center and spreads to periphery
common shapes and configurations - confluent
lesions run together