skin and tissue integrity Flashcards

(54 cards)

1
Q

skin color is derived from what three sources

A

Melanin—brown pigment
Carotene—yellow-orange pigment
Red purple tones in the underlying vascular bed

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2
Q

all individuals have what difference with skin color

A

 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

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3
Q

the skin is and has what

A

 Skin is washable, waterproof, & rugged -> has protective & adaptive properties

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4
Q

the types of functions of skin

A

protection
prevents penetration
perception
fluid balance
temperature regulation
identification
communication
wound repair
absorption and excretion
production of vitamin D

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5
Q

medications - tetracycline

A
  • given a lot for people with acne
    • makes the skin more sensitive and prone to sunburns
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6
Q

subjective data health history questions

A

 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

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7
Q

inspect and palpate the skin - color

A

 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

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8
Q

inspect and palpate the skin - temperature

A

 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

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9
Q

inspect and palpate the skin - what to check for in moisture

A

diaphoresis
dehydration

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10
Q

inspect and palpate the skin - lesions

A

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

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11
Q

ABCDEF skin assessment (exam)

A
  • 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
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12
Q

what should you do for the ABCDEF skin assessment

A

 Promoting health and self-care
 Teach skin self-examination using ABCDEF rule to detect suspicious lesions

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13
Q

developmental competence: infant skin presentations

A

 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

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14
Q

developmental competence: life-cycle presentations - adolescents

A

 Adolescent
 Acne
 Open and closed comedones

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15
Q

developmental competence: life-cycle presentations - pregnancy

A

 Striae (stretch marks)
 Linea nigra
 Chloasma
 Vascular spiders

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16
Q

developmental competence: life-cycle presentations - aging for skin color and presentations (exam)

A
  • Solar lentigines (liver spots) -> dark spots, often from sun exposure
  • Keratoses -> seborrheic or actinic
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17
Q

developmental competence: life-cycle presentations - aging for moisture (exam)

A

xerosis - dry skin

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18
Q

developmental competence: life-cycle presentations - aging for texture

A
  • Skin tags or acrochordons
  • Sebaceous hyperplasia
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19
Q

developmental competence: life-cycle presentations - aging for thickness

A

Thin parchment as subcutaneous fat decreases

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20
Q

developmental competence: life-cycle presentations - miscellaneous

A

 Decreased mobility and turgor
 Decreased hair growth, nail growth, and brittle nails

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21
Q

define xerosis

A

known as dry skin
- excessive dry skin

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22
Q

detecting color changes in light and dark skin

A

Be aware of normal variations for the following variables:
 Pallor
 Cyanosis
 Erythema -> redness and swelling of the skin
 Jaundice -> often shows liver damage

23
Q

common shapes and configurations - annular or circular

A

begins in the center and spreads to periphery

24
Q

common shapes and configurations - confluent

A

lesions run together

25
common shapes and configurations - discrete
distinct and separate
26
common shapes and configurations - grouped
cluster of lesions
27
common shapes and configurations - gyrate
twisted, coiled, or snakelike
28
common shapes and configurations - target or iris
resembles iris of the eyes, concentric rings
29
common shapes and configurations - linear
scratch, streak, line, or stripe
30
common shapes and configurations - polycyclic
annular lesions grow together
31
common shapes and configurations - zosteriform
linear arrangement following a unilateral nerve route
32
primary skin lesions - macule (exam)
 Solely a color change, flat and circumscribed, less than 1 cm - will not feel it
33
primary skin lesions - papule
 Felt and caused by superficial thickening of the epidermis
34
primary skin lesions - patch
 Macules that are larger than 1 cm
35
primary skin lesions - plaque
 Papules coalescing to form surface elevation wider than 1 cm
36
primary skin lesions - nodule
 Solid, elevated, hard or soft, greater than 1 cm that may extend deeper into dermis than papule
37
primary skin lesions - wheal
 Superficial, raised, transient and erythematous, irregular in shape due to edema - multiple clustered together is hives
38
primary skin lesions - tumor
 Larger in diameter, firm or soft, deeper into dermis, may be benign or malignant
39
primary skin lesions - urticaria (hives)
 Wheals coalesce to form extensive pruritic reaction.
40
primary skin lesions - vesicle
 Elevated cavity containing fluid up to 1 cm (blister)
41
primary skin lesions - cyst
 Encapsulated fluid filled cavity
42
primary skin lesions - bulla
 Larger than 1 cm diameter, usually single chamber, superficial in dermis and ruptures easily
43
primary skin lesions - pustule
 Pus in cavity that is circumscribed and elevated.
44
secondary skin lesions - debris of skin surfaces
 Crust—Thickened dried out exudate  Scale—Compact flakes of desiccated skin from shedding of dead excess keratin cells
45
secondary skin lesions - break in continuity of skin surfaces
 Fissure—Linear crack with abrupt edges extending into dermis  Erosion—Scooped out but shallow depression  Ulcer—Deeper depression extending into dermis with irregular shape, may bleed, leaves scar  Excoriation—Self-inflicted abrasion that is superficial  Scar—Permanent fibrotic change after healing  Atrophic scar—Resulting skin level is depressed with loss of tissue and thinning  Lichenification—Prolonged intense scratching leads to thickened skin producing tightly packed set of papules  Keloid—Benign excess of scar tissue beyond original injury
46
stages of pressure injuries (exam)
 Stage I: Non-blanchable erythema  Stage II: Partial-thickness skin loss  Stage III: Full-thickness skin loss  Stage IV: Full-thickness skin/tissue loss
47
DTPI
deep tissue pressure injury - can be caused by medical devices
48
hemangiomas
 Port-wine stain (nevus flammeus)  Strawberry mark (infantile hemangioma)  Deep hemangioma (mature)
49
telangiectases
 Spider angioma  Venous lake
50
pupuric lesions
 Petechiae  Ecchymosis  Purpura
51
lesions caused by trauma or abuse
 Mechanical injury  Contusion (bruise)
52
common skin lesions in children
 Diaper dermatitis  Candidiasis  Impetigo  Atopic dermatitis (eczema)  Measles (rubeola)  German measles (rubella)  Chickenpox (varicella)
53
common skin lesions in general
 Primary contact dermatitis  Allergic drug reaction  Tinea corporis (ringworm of the body)  Tinea pedis (ringworm of the foot)—Athlete's foot  Labial herpes simplex (cold sores)  Tinea versicolor  Herpes zoster (shingles)  Erythema migrans of Lyme disease  Psoriasis
54
types of malignant skin lesions
Basal cell carcinoma  Squamous cell carcinoma  Malignant melanoma