Skin Assessment Flashcards
(90 cards)
1
Q
Name the 3 layers of skin
A
Epidermis, Dermis, Subcutaneous
2
Q
Deepest layer of epidermis
A
Stratum germinativum or basal cell layer
3
Q
Most superficial layer of epidermis
A
Stratum corneum or horny cell layer
4
Q
Derivation of skin color comes from the
A
epidermis
5
Q
Includes connective tissue or collagen and elastic tissue
A
Dermis
6
Q
Name the 4 epidermal appendages
A
- Hair 2. Sebaceous glands 3. Sweat glands 4. Nails
7
Q
Name 2 types of sweat glands
A
Apocrine-open into hair follicle Eccrine-occur over most of your body and open directly onto surface of skin
8
Q
The following are functions of the _______
Protection Prevents penetration Perception Temperature regulation Identification
A
Functions of Skin
9
Q
The following are functions of the ____
Communication Wound repair Absorption and excretion Production of vitamin D
A
Functions of Skin
10
Q
The following are what you would ask when conducting someone’s _____- Common or Concerning Symptoms Client’s Personal Health History Family History Lifestyle and Personal Habits
A
Subjective Health History
11
Q
What items do you need when conducting a physical exam?
A
Strong direct lighting, Small centimeter ruler, Penlight, Gloves
12
Q
When inspecting skin, you are looking for ___(4)
A
Color, Odor, Integrity, Lesions
13
Q
You are looking for these things while _____ the skin Texture Thickness Moisture Temperature Mobility and Turgor Edema Lesions
A
Palpating
14
Q
How do you test for skin turgor
A
Pinch skin underneath clavicle
15
Q
What are you looking for while inspecting lesions?
A
Size include number of lesions, Shape or Pattern, Color, Texture Surface Relationships and Pattern Exudate Tenderness or Pain Body Location and Distribution
16
Q
Distribution of skin lines include:
A
- Diffuse/Generalized
- Scattered
- Localized
- Regional
- Torso
- Extensor/Flexor Surfaces
- Dermatome Line
Hairy Areas
17
Q
Circular lesions
A
Annular
18
Q
Circular configurations that run together
A
Confluent
19
Q
Separate lesions that are not joined to one another
A
Discrete or distinct lesions
20
Q
Lesions that are very close to one another in a cluster
A
Clustered or grouped lesions
21
Q
Twisted or coiled lesions
A
Gyrate
22
Q
Lesions that look like little targets
A
Target, concentric rings of color
23
Q
Lesions that look like a streak
A
Linear, streak or stripe
24
Q
Annular lesions growing together
A
Polycyclic
25
Linear lesions growing along a nerve root
Zosteriform
26
Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). Less than 1 cm with a circumscribed border, include freckles, petechiae, and flat moles.
Macule
27
Flat, are greater than 1 cm, and may have an irregular border.
Patch
28
Elevated, palpable, solid mass. Have a circumscribed border and are less than 0.5 cm; include warts
Papule
29
Elevated, palpable, solid mass; are greater than 0.5 cm and may be coalesced with a flat top. Include psorias
Plaque
30
Elevated, solid, palpable mass that extends deeper into dermis than a papule. Are 0.5–2 cm and circumscribed; include keloid, lipoma, squamous cell carcinoma, poorly absorbed injection, and dermatofibroma
Nodule
31
Elevated, solid, palpable mass that extends deeper into dermis than a papule. Are greater than 1–2 cm and do not always have sharp borders. Examples include larger lipoma and carcinoma.
Tumor
32
Circumscribed elevated, palpable mass containing serous fluid; less than 0.5 cm; Examples include herpes simplex/zoster, varicella (chickenpox, pictured below), poison ivy, and second-degree burn.
Vesicle
33
Circumscribed elevated, palpable mass containing serous fluid; are greater than 0.5 cm; include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.
Bulla
34
Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; **it does not contain free fluid in a cavity.** Examples include urticaria (hives) and insect bites.
Wheal
35
Pus filled vesicle; Example is acne
Pustule
36
Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis.
Cyst
37
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
cyanosis
38
a condition in which the skin, whites of the eyes and mucous membranes turn yellow because of a high level of bilirubin, a yellow-orange bile pigment
jaundice
39
an unhealthy pale appearance.
pallor
40
Characterized by, or causing, a morbid redness of the skin
erythematic
41
Loss of superficial epidermis that does not extend to the dermis. It is a depressed, moist area.
Erosion
42
Examples include rupture vesicle, scratch mark, and aphthous ulcer (aphthous stomatitis, commonly called a canker sore
Erosion
43
Skin loss extending past epidermis, with necrotic tissue loss. Bleeding and scarring are possible.
Ulcer
44
Examples include stasis ulcer of venous insufficiency
Ulcer
45
Skin mark left after healing of wound or lesion that represents replacement by connective tissue of the injured tissue. Young scars are red or purple, whereas mature scars are white or glistening
Scar
46
Examples include healed wound and healed surgical incision.
Scar
47
Linear crack in the skin that may extend to the dermis and may be painful.
Fissure
48
Examples include chapped lips or hands and athlete’s foot.
Fissure
49
Flat, red or purple macules bleeding from superficial capillaries
Petechia
50
Thickened Skin
Lichentification
51
Excessive collagen formation
Keloid
52
How do you evaluate for moles/skin cancer? List the A's through G's and explain what each stands for
A—asymmetry
B—border
C—color
D—diameter
E—evolving
E - elevated
F - firm to palpation
G - growing progressively over several weeks
53
Symmetrical, Borders even, One color, Smaller than 6mm, Ordinary mole, flat or raised surface
Benign
54
Asymmetrical, borders uneven, two or more colors, larger than 6mm, changing in size, color or another shape, elevated, firm to palpation
Malignant
55
•Papule with Pearly borders – volcano like
Basal Cell Carcinoma
56
Central ulcer with reddened borders
Squamous Cell Carcinoma
57
A skin cancer that begins in cells called melanocytes; brown-to-black pigmented lesions
Malignant Melanoma
58
Risk factors of skin cancer
* Sun exposure
* Nonsolar sources of ultraviolet radiation
* Medical therapies
* Family history and genetic susceptibility
* Moles
* Pigmentation irregularities
* Fair skin that burns and freckles easily; light hair
* Age
* Male gender
* Chemical exposure
* Human papillomavirus
* Xeroderma pigmentosum
* Long-term skin inflammation or injury
* Alcohol intake; smoking
* Inadequate niacin in diet
59
How do you reduce risk of skin cancer
* Reduce skin exposure.
* Always use sunscreen when sun exposure is anticipated.
* Wear long-sleeve shirts and wide-brimmed hats.
* Avoid sunburns.
* Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers.
* Have annual skin cancer screenings.
Diet adequate in Vitamin B3 (Niacin)
60
How do you reduce pressure injury risk?
* Inspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document.
* Bathe with mild soap or other agent; limit friction; use warm, not hot, water; set bath schedule that is individualized.
* For dry skin: use moisturizers; avoid low humidity and cold air.
Avoid vigorous massage.
* Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point.
* Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient.
* Refer incontinence condition to primary care provider.
* Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products
61
How do you assess nails?
Inspect and Palpate
Grooming and Cleanliness
Color and shape
Texture and Consistency
Capillary Refill
62
What happens to nails as you age?
Thickened, yellow, brittle, lackluster
Longitudinal ridges, striations
Ingrown toenails
63
How do you assess the scalp and hair?
Inspect and Palpate
* Color
* Texture
* Distribution
* Lesions
64
Increased hair growth on chin and around lips in older \_\_\_\_\_
females
65
Increased hair growth in ears, nostrils, and eyebrows in older\_\_\_\_\_\_\_
males
66
Spot baldness is called \_\_\_\_\_\_
Alopecia
67
In regards to hair with aging, there is loss of \_\_\_\_\_\_\_and decreased \_\_\_\_\_\_\_\_
pigment; axillary/pubic/extremity hair
68
What are some tips for maintaining healthy skin of the aged?
* Drink at least 2 quarts of water daily
* Maintain a well balanced diet with ample fruits, vegetables, and protein
* Use skin creams and lubricants that moisturize the skin at least twice daily
* Use mild, or super-fatted, non-perfumed soaps
* Bathe in warm water and rinse the skin well before drying thoroughly
* Keep the air in the home humidified
* When outside use sunscreen that cover UVA and UVB rays with an SFP of 30 or higher and lip balm even on cloudy days
* When in the sun wear cotton clothing that covers the body such as long pants, long sleeves, a wide brimmed hat, and sunglasses
* Limit time in the sun and exposure to cold and wind
* Limit full body bathing to two or three times a week
* If incontinent, make sure the skin is washed well and dried thoroughly, and that an emollient is applied
* Avoid, rough, irritating clothing or laundering clothes with harsh soaps, bleach, or starch
69
A warty or crusty pigmented lesion; appears as a waxy brown, black, or tan growth; noncancerous.
Seborrheic Keratosis
70
A thick, scaly patch of skin that may become cancer. It usually forms on areas exposed to the sun, such as the face, scalp, back of the hands, or chest. It is most common in people with fair skin.
Senile Keratosis
71
A small piece of soft, hanging skin that may have a peduncle, or stalk. They can appear anywhere on the body, but especially where skin rubs against other skin or clothing.
Skin Tags
72
Benign, easy bruising that affects older adults. This occurs because the skin and the blood vessels become more fragile as we age, making it easier for our skin to bruise from minor trauma.
Senile Purpura
73
A benign pigmented flat spot on sun-exposed skin in older adults, especially on the back of the hands and on the forehead. Also called a liver spot.
Senile Lentigines
74
Small raised spots (1–5 mm wide) typically seen with aging.
Cherry Angioma
75
The following are all symptoms of\_\_\_\_\_\_\_
Thinning epithelium
Wrinkles, looses turgor and becomes lax
Dry, itchy skin; Pale in color
aging
76
180-degree angle of nails with spongy sensation that can occur from hypoxia.
clubbing
77
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage 1 Pressure Ulcer
78
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister.
Stage 2 Pressure Ulcer
79
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage 3 Pressure Ulcer
80
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Stage 4 Pressure Ulcer
81
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined
Unstageable Pressure Ulcer
82
What are the most common sites for pressure ulcers?
Over a bony prominence, such as the butt, heels, hips, elbows, ankles, back and shoulders
83
Includes 6 categories; Sensory Perception, Moisture, Nutrition, Activity, Mobility, Friction and Shear
Braden Scale
84
Uses a score from less than or equal to 9 to as high as 23. The **lower the number, the higher the risk** for developing an acquired ulcer/injury; goes from completely limited-very limited-slightly limited-no impairment.
Braden Scale
85
Name 6 Pressure Injury Factors
* Perception
* Mobility
* Moisture
* Nutrition
* Friction or shear against surfaces
* Tissue tolerance decreased
86
Developed in the 1960s and is widely used to assess the risk for pressure ulcer in adult patients. The five subscale scores of are added together for a total score that ranges from 5-20. A **lower score indicates higher levels of risk** for pressure ulcer development.
Norton Scale
87
What are the 5 components of the Norton Scale?
Physical Condition
Mental Condition
Activity
Mobility
Continence
88
When palpating nails, they should \_\_\_\_\_\_\_
Return with normal color (pink)
89
What do the following ranges for the Braden Scale mean?
19-23
15-18
13-14
less than 9
no risk; mild risk; moderate risk; severe risk
90
What do the following scores interpret to for the Norton Scale?
\<10
10 – 14
14 – 18
\>18
very high risk; high risk; medium risk, low risk
