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Skin/Pain Assessment

Health Assessment

TermDefinition
The skin contains three layers: Epidermis, Dermis, & Beneath these layers is a third layer, the subcutaneous layer of adipose tissue.
Epidermis: The outer layer of skin. This layer is thin but tough. Its cells are bound tightly together into sheets that form a rugged protective barrier.
Dermis: The dermis is the inner supportive layer consisting mostly of connective tissue or collagen.
Subcutaneous Layer: This layer is adipose tissue, which is made up of lobules of fat. The subcutaneous tissue stores fat for energy, provides insulation for temperature control, and aids in protection by its soft cushioning effect.
Hair: Hairs are threads of keratin. The hair shaft is the visible projecting part, and the root is below the surface embedded in the follicle.
Nails: Nails are hard plates of keratin on the dorsal edges of the fingers and toes.
Glands: (sebaceous) These glands produce a protective lipid substance, sebum, which is secreted through the hair follicles. Sebaceous glands are everywhere except the palms and soles. Most abundant in the scalp, forehead, face, and chin.
Sweat Glands: There are two types: Eccrine glands and Apocrine glands
Eccrine Glands: are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat.
Apocrine Glands: produce a thick, milky secretion and open into the hair follicles. They are located mainly in the axillae, anogenital area, nipples, and naval.
Functions of the Skin: Provides barrier, Regulates body temperature, Synthesizes vitamin D, Sensory perception, Provides nonverbal communication, Provides identity, Allows wound repair, Allows excretion of metabolic waste
Functions of the Skin: (continued) wound repair, absorption and excretion, production of vitamin D
Wound Repair: skin allows cell replacement of surface wounds.
Absorption and Excretion: skin allows limited excretion of some metabolic wastes, by-products of cellular decomposition such as minerals, sugars, amino acids, cholesterol, uric acid, and urea.
Vitamin D: the skin is the surface on which ultraviolet light converts cholesterol into Vitamin D.
Skin and the Aging Adult: The epidermis’s out layer thins. Wrinkling occurs because the dermis thins and flattens. Sweat glands and sebaceous glands decrease in number and function, leaving the skin dry.
Skin and the Aging Adult cont: A loss of elastin, collagen, and subcutaneous fat occurs as well as muscle loss. Vascularity of the skin decreases with fragility increasing. Example : senile purpura.
Skin and the Aging Adult cont: Hair becomes thin, fine, gray or white caused by the decrease in the number of functioning melanocytes.
History Questions for Skin: Subjective Data Rash, Non-healing lesions, Moles, Lesions, Bruising, Hair loss, Previous history of skin disease, Family history of skin disease, allergies, birthmarks, tattoos, Lifestyle and personal habits, Medications prescribed and OTC
Subjected Data (cont) - for states problem: PQRSTU-or eight critical characteristics: location, character/quantity, quantity/severity, timing: onset, duration, frequency, better or worse, associated factors or symptoms.
History for the Aging Adult: Changes noticed in the past few years. Delays in wound healing, Any skin pain Changes in feet, toenails, bunions, problems with shoe wearing. Frequent falls. History of diabetes, peripheral vascular disease. How do you care for your skin?
History for Pedi: Does the child have any birthmarks? Was there any change in skin color as a newborn?Any jaundice? Which day after birth? Any cyanosis? Under what circumstances?
History for Pedi (cont): Rash? Related to new foods, formula, chocolate, cow’s milk, eggs? Ask about origin of any bruises/burns. Use sunscreen?
Physical Exam - Objective Data: Inspect and palpate the skin: Observe color and pigmentation: freckles, nevus, birthmarks. Color changes: pallor, erythema, cyanosis, jaundice.
Physical Exam - Objective Data: (cont) Temperature: Hypothermia - generalized coolness. Hyperthermia- occurs with increased metabolic rate such as fever, exercise, trauma, infection or sunburn. Use the back of your hands to assess.
Physical Exam - Objective Data: (cont) Moisture: Look for diaphoresis-increased perspiration. Look for excess dryness, dehydration-check oral mucous membranes, mobility and skin turgor.
Physical Exam - Objective Data: (cont) Texture and thickness: Normal skin feels smooth and firm and with an even surface. Also check for Edema and bruising. Check for lesions.
Lesions: if lesions are present: Location and distribution, Pattern or shape: annular, grouped, confluent, linear. Type of skin lesion, Color, Elevation: flat, raised, umbilicated, Size: in centimeters, Exudate: color and odor.
Pressure Sore Evaluation: Braden Scale – see page 162
Primary Lesions: the immediate result of a specific causative factor, lesions develop on unaltered skin.
Macule: Color change, flat, less then 1 cm.- freckles, petechiae, measles, scarlet fever.
Papule: Raised, solid, less then 1 cm- nevus, wart.
Patch: Greater then 1 cm- café au lait spot, mongolian spot.
Plaque: Raised disk shaped lesion- psoriasis, or lichen planus.
Nodule: Solid elevated lesion >1cm
Tumor: >then a few cm, firm or soft, deeper into the dermis.
Wheal: Superficial, raised,transient,and erythematous. Slightly irregular shaped, fluid filled-mosquito bite, allergic rxn.
Uticaria: example: hives, intensely pruritic, reaction.
Cyst: Elevated, encapsulated fluid filled cavity in the dermis or subcutaneous layer.
Vesicle: Elevated cavity containing clear fluid, up to 1 cm-herpes, varicella.
Bulla: >1cm superficial- blister
Pustule: Elevated turbid (pus) fluid filled cavity-acne, impetigo.
Secondary Skin Lesions: Resulting from a change in primary lesion.
Crust: Thickened dried out lesion-yellow, brown or honey colored.
Scale: Flakes, dry or greasy, silvery or white, shedding of dead excess keratin cells.
Fissure: Linear crack with abrupt edges.
Erosion: Scooped out shallow depression.
Ulcer: Deeper depression extending into the dermis.
Excoriation: Self inflicted abrasion, superficial, crusted.
Scar: After skin lesion is repaired, normal tissue is lost and replaced with collagen. Permanent fibrotic change.
Atrophic Scar: Skin level depressed with loss of tissue.
Lichenification: Caused by prolonged intense scratching which thickens the skin.
Keloid: A hypertrophic scar resulting in elevated scar tissue.
Physical Exam of Skin - Objective Data: Skin Inspect, palpate, note any lesions, teach self examination ABCDE
Inspect: color, general pigmentation, abnormal color changes.
Palpate: temperature, moisture, texture, thickness, edema, mobility and turgor, hygiene, vascularity and bruising.
Note any lesions: color, shape and configuration, size, location and distribution.
Hair and Nails: Inspect and Palpate Hair: texture, distribution, scalp for lesions, flakes, lice, nits. Inspect body, axillae and pubic hair. Inspect and Palpate Nails: shape and contour, consistency, color.
Pain Assessment: often regarded as 5th vital sign.
Acute Pain: pain associated with a severe illness/injury.
Chronic Pain: pain lasting more than 1 month.
Assessing the patient's pain: Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations, Relieving Factors, Treatments
Types of Pain: Nociceptive or Somatic Pain, Neuropathic Pain, & Psychogenic and Idiopathic Pain
Nociceptive or Somatic Pain: pain related to tissue damage.
Neuropathic Pain: pain resulting from direct injury to the peripheral or central nervous system.
Psychogenic and Idiopathic Pain: psychogenic pain relates to many factors that influence the patient’s report of pain such as psychiatric conditions: depression, anxiety, coping skills and cultural norms and ideopathic pain is without any identifiable etiology.
Pain Assessment and Management: Appropriate pain assessment is important to assure quality pain care. It may be challenging with pediatric patients and cognitively impaired older adults.
Pain Assessment and Management: (cont) Pain measurement scales used – see next slide. Focus on the Four A’s to monitor patient outcomes: Analgesia, ADLs, Adverse effects Aberrant drug-related behaviors.
Created by: mr209368