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301_Skin

Skin for Health Assessment

QuestionAnswer
What are common integumentary findings in African Americans? Keloid formation, traction alopecia, pseudofolliculitis, folliculitis barbarae, and perineal follicularis
What skin findings require prompt evaluation and intervention with fluids, oxygen admin, and skin repair? Findings indicating dehydration, cyanosis, or impaired skin integrity (acute lacerations).
If a patient has a specific concern about his skin, when do you look at it? Inspect the area/lesion first, then ask other questions.
What are the ABCDEF's of melanoma detection? Asymmetry, Border irregularity, Color, Diameter of more than 6mm, Evolution over time, Friend
The presence of what on the skin increases risk for melanoma? Any dysplastic nevi, or more than 50 normal moles.
What is phototoxicity? A reaction caused by a medication's molecules absorbing energy from a particular UV wavelength and then damaging surrounding tissues.
What is photosensitivity? medications, sunscreens, perfumes, cosmetics and topical skin creams cause a reaction on the skin that usually presents with a rash after sun exposure.
What is photoallergy? Manifests with blisters and redness on exposed skin, occurs only after repeated exposure to an offending substance, and persists for some time after removal of the offending substance, UV exposure, or both.
What 5 features do normal moles possess? 1. Solid, tan, brown, black, or skin-colored. 2. Smaller than 6mm 3. Well-defined edges 4. Round or oval shape. Flat or dome-like surface 5. Emergence before 30 years of age.
Severe pruritis interfering with sleep is usually from what? Scabies
Localized pruritis is usually caused by what? infestation, insect bite, allergic reaction, toxic exposure.
Generalized pruritis is usually caused by what? Medication and food allergies
Impetigo results from what type of infection? Either Staph or Strep
What type of skin lesions are distinct and walled off, containing fluid or semi-solid material? Vary in size... Cysts
What skin lesion is purulent, fluid-filled, raised of any size? Example? Pustule. Ex: Pustular acne
What skin lesion is fluid-filled, >1 cm diameter? Example? Bulla. Ex: Second-degree burns
What skin lesion is fluid-filled, <1 cm diameter? Example? Vesicle. Ex: Herpes simplex, Chicken Pox
What skin lesion is flat, circumscribed, discolored, <1 cm diameter? Example? Macule. Example: Freckles, stork bite.
What skin lesion is flat, circumscribed, discolored, >1 cm diamter? Example? Patch Ex: Vitiligo, melasma
What skin lesion is raised, defined, any color, >1 cm diameter? Examples? Plaque. Ex: Psoriasis
What skin lesion is solid, palpable, >1 cm diamter, often with some depth? Example? Nodule. Ex: Basal Cell Carcinoma
What skin lesion is raised, flesh-colored, or red edematous papules or plaques, vary in size and shape? Example? Wheal. Ex: Urticaria
What skin lesion is raised, defined, any color, <1 cm diameter? Example? Papule. Ex: Wart, insect bite
Fissure? linear break in skin surface, not related to trauma.
Excoriation? lesion resulting from scratching or excessive rubbing of skin
Lichenification? Accentuation of normal skin lines resembling tree bark. Commonly caused by excessive scratching.
Polymorphous lesions? several different shapes. Ex: Urticaria, tinea corporis
Punctuate lesions? Small, marked with points or dots Ex: Petechiae, Rocky Mountain spotted fever.
Serpinigous Lesions? Curving, snake-like. Example: Scabies
Iris Lesions? Bull's Eye. Ex: Lyme Disease
Annular Lesions? Ring-like, circular. Ex: Tinea Corporis
Verrucaform Lesions? Circumscribed, papular with rough surface. Ex: Warts
Filiform Lesions? Papilla-like for finger-like projections (similar to tongue papillae). Ex: warts
Nummular/Discoid Lesions? Coin-Shaped. Ex: Nummular psoriasis
Umbilicated Lesions? Central Depression. Ex: Herpes Zoster
Zosteriform Lesions? Distributed along dermatome. Ex: Herpes Zoster
Satellite Lesions? Single lesions in close proximity to larger lesion. "orbiting" Ex: Cutaneous Candidiasis
Confluent Lesions? With enlargement or multiplication, begin to coalesce for form larger lesion. Ex: Urticaria
Describe Primary vs. Secondary morphology of lesions? Primary= Type Secondary= Shape, Size, Arrangement, and distribution, which further defines the underlying problem.
Give Examples of Primary vs. Secondary Lesions Primary= maculae, papules, nodules, tumors, polyps, wheals, blisters, cysts, pustules, abcesses. Secondary= follow primary lesions (scar tissue, crusts from dried burns).
Patients with a Braden Score of ______ have a low risk of developing a pressure ulcer. 15 or 16
Patients with a Braden Score of _______have a moderate risk of developing a pressure ulcer. 13 or 14
Patients with a Braden Score of _______have a high risk of developing a pressure ulcer. 12 or less
True or False? Patients with a total Braden score of 16 or less are considered to be at risk of developing pressure ulcers? TRUE
What six categories does the Braden Scale look at when assessing for pressure ulcers? 1. Sensory Perception (ability to respond to pressure-related discomfort) 2. Moisture exposure of skin 3. Activity level 4. Mobility 5. Nutrition 6. Friction and Shear
Each leg is given what percentage in regards to the TBSA and burn classification? 18%
Each arm is given what percentage in regards to the TBSA and burn classification? 9%
The Head, Anterior, Posterior and Pubic Area are given what percentages in regards to the TBSA and burn classification? Head: 9% Anterior: 18% Posterior: 18% Pubic Area: 1%
Skin Assessment involves what? General color Texture Moisture Turgur Temperature *Focused inspection and palpation of rashes, lesions, or wounds.
What eight things do you assess a wound for? 1. location 2. Size 3. color 4. texture 5. drainage 6. margins 7. surrounding skin 8. healing status
What are the four depths of burns? 1. Superficial- (epidermal layers) 2.superficial-dermal (epidermis and pt of dermis) 3. dermal (epidermis and all of dermis) 4. full-thickness (all layers of skin and my extend to supportive fascia below)
When assessing a lesion, what do you identify? (6 things) 1. configuration 2. pattern 3. morphology 4. size 5. distribution 6. exact body location
When assessing hydration in an infant, where do you pinch a fold of skin? On the abdomen
An adult white patient visits your clinic for the first time. During assessment of the client's skin, the RN should assess for central cyanosis by observing the patient's? Oral mucosa/ mouth
What are Beau's lines? What are they related to? A linear indentation on nailbed from slow or halted nail growth. Related to illness, physical trauma or poisoning.
The only layer of the skin that undergoes cell division is the: Innermost layer of the epidermis.
What is Telangiectasis? Superficial dilation of venous vessels.
What is Onycholysis? Detachment of the nail plate.
Describe Stage III pressure ulcers. Full thickness tissue loss. SubQ fat may be visible but bone, tendon, or muscle is not not exposed
Describe Stage II pressure ulcers. Partial thickness loss of dermis. Presents as shallow open ulcer with a red pink wound bed. NO SLOUGH!
Describe Stage I pressure ulcers. INTACT SKIN! With nonblanchable redness of a localized area. Usually over bony prominence. Area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Describe Suspected deep tissue injury Purple or maroon localized area of discolored, intact skin. OR, blood-filled blister from damage to underlying soft tissue. Result from pressure, shearing or both.
Describe Stage IV pressure ulcer. Full thickness tissue loss WITH exposed bone, tendon, or muscle. Slough or eschar may be present. Tunneling!
Describe Unstageable pressure ulcer Full thickness tissue loss in which the base of the ulcer is covered by slough(yellow, tan, gray, green, or brown), eschar (tan, brown, or black) or both. True depth cannot be determined.
Should you remove eschar from heels of feet? NO! As long as it is stable (dry, adherent, intact) it serves as the body's natural cover.
Neuropathic ulcers are commonly caused by what? Diabetes
When do you use the Wagner's Classification of ulcers? To determine grade of neuropathic ulcer. (caused by diabetes)
What 5 skin conditions in newborns are indications of greater risk for morbidity and mortality? 1. Progressive Jaundice 2. Pallor 3. Cracked or peeling skin 4. Cafe au lait spots >3cm, and more than 6 in number. 5. Stiff or immobile skin
What is carotenemia caused by? Symptoms? Caused by Excessive ingestion of yellow or orange veggies, or chronic renal disease. Symptoms: yellowish palms, soles and face (NOT SCLERAE) in infants and children.
Physiologic vs Pathologic Jaundice? Physio= Occurs after 24 hours and persists 72 hours. Path= Appears in first 24 hours of birth.
How do you verify Jaundice? Apply light pressure to skin to cause blanching. JAUNDICE DOES NOT BLANCHE!!! yellowish skin from OTHER causes will turn white.
What are 3 abnormal skin findings in pregnancy? 1. Pyogenic granuloma (red papulee or nodule on lips- bleeds easily) 2. Erythema nodusm (tender, red, painful nodules on legs) 3. PUPPP- pruritic urticarial papules and plaques of pregnancy (intensely itchy red papules and plaques within stretch-marks)
Hair inspection...The closer to the scalp a nit is located, the more _______ the infestation. RECENT!!!
Clubbing of nails. Angle of nail is more than ______degrees. 160
In female patients, ovarian dysfunction may be characterized by??? Hair on beard area, abdomen, upper back, shoulders, sternum, and inner upper thighs
What part of your hand do you use to palpate for skin temperature? Dorsal Surface
What part of your hand do you use to palpate for skin moisture and texture? Palmar surface of fingers and hands
How do you assess for vascularity? Apply direct pressure to the skin surface with the pads of your fingers. Will cause skin to blanche in comparison with surrounding skin.
What areas are the best places to look for pallor or cyanosis? Why??? tongue, lips, nail beds, and buccal mucosa. Because they are less pigmented areas.
The healing process is divided into what 3 phases? 1. Inflammatory 2. Proliferative 3. Remodeling
Why does skin tear easily in the older population? Aging causes the junction between the dermis and epidermis to flatten, increasing the tendency of the skin to tear.
How do the lesions progress in Varicella? Begins with macular lesions, progresses to papular, then vesicular, and ultimately superficial ulcers.
What infectious skin disorders also have fever and chills? Measles, Rubella, Varicella
Headache often accompanies what two skin disorders? Mumps, meningitis
What are the steps in the Self Skin Examination? 1. Get naked and stand in front of full length mirror 2. Scan entire body using hand-held mirror 3. Use a comb for blowdryer to examine sections of scalp 4. Report any suspicious lesion to healthcare provider
UVB waves vs UVA waves? UVB= more likely to cause sunburn. UVB= directly linked to skin cancer UVA= Responsible for wrinkling and leathering of skin
Created by: SSPrather on 2011-03-02



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