Skin Assessment

Question 0

Stratum Corneum

Answer 0

Contains dried keratinocytes for protection, permeability barrier
Disease of this layer includes tinea versicolor, a fungal infection

Question 1

The Skin

Answer 1

• Reflects inner health
• Barrier, protects and prevents penetration
• perception, sensation
• thermoregulation
• absorbs and excretes
• identification
• communication
• synthesized vit D

Question 2

Epidermis

Answer 2

• Cells in progression are as follows:
• Basal to spinous to granular layers with keratinocytes, melanocytes, langerhan’s cell and Merkel cell
• Diseases include psoriasis, exfoliative dermatitis, ichtyosis vulgaris, and keratosis follicularis
• outermost part of skin
• avascular
• epithelial cells
• 4-5 layers, palms and soles have additional layers

Question 3

Keratinocytes

Answer 3

Non-hyperproliferative disease (ichtyosis vulgaris)
Benign hyperproliferative diseases (psoriasis, actinic keratosis)
Malignant diseases ( basal cell CA, squamous cell CA)

Question 4

Melanocytes

Answer 4

Diseases include albinism (reduces melanocytes) and Addison’s Disease (increased pigmentation)

Question 5

Langerhan’s cells

Answer 5

Disease includes contact eczematous dermatitis

Question 6

Merkel Cells

Answer 6

Slowly adapting mechanoreceptors

Question 7

Basement Membrane Zone

Answer 7

Diseases include bullous penphigoid, herpes gestationes, and systemic lupus erythematosus

Question 8

Dermis

Answer 8

• Loose connective tissue with collagen, elastin, reticulin; cells are fibroblasts, macrophages, mast cells, lymphocytes.
• Structures include blood vessels, lymphatic vessels, nerves, sweat glands, apocrine, and sebaceous glands (lipid secretions)
• Diseases include scleroderma and urticaria
• supportive layer

Question 9

Appendages

Answer 9

Hair
Sebaceous glands
Sweat glands
Nails

Question 10

RBC lives

Answer 10

120days

Question 11

WBC lives

Answer 11

18-24hrs

Question 12

Subcutaneous layer

Answer 12

• comprised of lobules of fat cells
• provides insulation
• aids in protection
• provides upper layers with increased mobility
• contains carotene

Question 13

Carotenes

Answer 13

Typical yellow-colored fat is a result of fat storage of these in their diet

Question 14

Aging Factors:EPIDERMIS

Answer 14

decreases thickness
-more fragile
-delayed wound healing
-hyperkeratoses and skin cancers
Increased permeability (decreased langerhan's cells)
-increased reaction 
-decreased inflammatory response 
Hyperplasia of melanocytes 
-liver spots
-age spots 
Decreased vit D
Risk of osteoporosis and osteomalacia 
Increased skin tears, purpura, and pressure ulcers

Question 15

Aging Factors: DERMIS

Answer 15

Decreased perfusion
-increase in dry skin
Decreased sensation 
-risk of injury 
Decreased vasomotor response
Risk of hypothermia/hyperthermia
Elastic fiber degeneration 
Wrinkles 
Proliferation of capillaries 
Cherry hemangiomas

Question 16

Aging Factors:SUBCUTANEOUS

Answer 16

Cellulite 
Bags over/under eyes 
Double chin
Abdominal fat increase 
Saggy breast 
Tenting when pinched (turgor tests)

Question 17

Aging Factors:GLANDS

Answer 17

Decrease in eccrine and apocrine
Dry skin
Absent perspiration

Question 18

Assessment

Answer 18

Look
Palpate
Smell
Ask questions 
Labs (albumin)
Braden scale

Question 19

Braden Scale

Answer 19

Sensory perception 
Moisture 
Activity 
Mobility 
Nutrition 
Friction/shear 

Mild risk:15-18
Moderate risk:13-14
High risk:10-12
Very high risk:9 or below

Implement PUP for Braden of 18 or less

Question 20

Assessment of Wounds or Ulcers

Answer 20

Acute wound or chronic wound 
Location 
Size (length, width, depth) 
Color
Cleanliness
Odor
Presence of wound drains 
Presence of drainage and exudate 
(Serous, serosanguineous, sanguineous, purulent)
Staging (1-4)

Question 21

Tissue Integrity Alterations

Answer 21

Corticosteroids 
(Thins skin/easily harmed)
Antibiotics
Chemo drugs
Psychotherapeutic drugs 
Impairs sun light sensitivity

Question 22

Pruitis

Answer 22

Itching associated with dry, scaly skin

May be symptoms of live or mite infestation

Question 23

Erythema

Answer 23

Redness accompanying inflammation

Question 24

Infectious: Bacterial

Answer 24

Boils, impetigo, infected hair follicles

Question 25

Infectious: fungal

Answer 25

Ringworm, athletes foot, jock itch, nail infection

Question 26

Viral

Answer 26

``` Cold sores Fever blisters (herpes simplex) Chickenpox Warts Shingles (herpes zoster) Measles (rubeola) German measles (rubella) ```

Question 27

Parasitic

Answer 27

Ticks Mites Lice

Question 28

Inflammatory

Answer 28

``` Overactive glands Increased hormones Infection Acne Rosacea Itching Cracking Discomfort Eczema Dermatitis Psoriasis Sunburn Environmental stresses ```

Question 29

Neoplastic

Answer 29

Malignant melanoma Basal cell carcinoma Squamous cell carcinoma

Question 30

ABCD

Answer 30

Asymmetry Border Color Diameter

Question 31

Macule

Answer 31

Freckles Flat, non-palpable Color change only, <1cm

Question 32

Patch

Answer 32

Macules >1cm

Question 33

Papules

Answer 33

Palpable Solid Raised <1cm diameter

Question 34

Plaque

Answer 34

Aggregations of papules/pustules that can be unroofed to leave denuded epithelium

Question 35

Coalesced papules

Answer 35

Plateau-like >1cm

Question 36

Nodule

Answer 36

Solid Elevated >1cm

Question 37

Tumor

Answer 37

Larger | > few cm

Question 38

Wheal

Answer 38

Superficial, raised, transient, irregular shape

Question 39

Urticaria

Answer 39

Coalesced wheals | Hives

Question 40

Psoriasis

Answer 40

Skin cells that multiply up to 10x faster than normal Cycles of remission and flare ups over time No cure Skin cells reach skin surface and die causing raised, red plaque covered with white scale

Question 41

Primary skin lesions

Answer 41

Vesicle Bulla Pustule Cyst

Question 42

Secondary skin lesions

Answer 42

``` Crust Scale Fissure Erosion Ulcer Excoriation Scar Atrophic scar Lichenification Keloid ```

Question 43

Vascular lesions

Answer 43

``` Port wine stain Strawberry Mark Cavernous hemangioma Spider or star angioma Venous lake Petechiae (DIC) Purpura (DIC) ```

Question 44

Lesion Assessment

Answer 44

ID anatomic location and distribution Note grouping or arrangement ID type Note Color

Question 45

Common Lesion Shapes

Answer 45

``` Annular or circular Confluent Discrete Grouped Gyrate Target Linear Polycyclic Zosteriform ```

Question 46

Crust of impetigo

Answer 46

Secondary to chicken pox

Question 47

Contact Dermititis

Answer 47

Inflammation of skin that occurs in response to direct contact with allergen or irritant -dyes, perfumes, poison plants, chemicals, metals, latex Hypersensitivity Irritant contact dermatitis -inflammation from irritants Soaps, chemicals, detergents

Question 48

Allergic Contact Dermatitis

Answer 48

Erythema, swelling, pruritic vesicles Rupture, ooze, crust Rash limited to area of contact

Question 49

Irritant contact dermatitis

Answer 49

Redness, edema, vesiculation, dryness of skin, scaling, fissures, and necrosis Patch testing

Question 50

Nursing Process

Answer 50

``` A-health assessment interview (chief complaint) examination D-impaired skin integrity Knowledge deficient P- Triggers identified and eliminated Free of infection I- medications to relieve symptoms Symptoms of infection Change environment or diet Barrier between allergen and skin Topical corticosteroids Reduce dry skin and relieve pruritus E-control dermatitis Triggers identified and eliminated Sleep minimally disturbed by itching ```