Skin assessment
| Description: | 314/315/ integementatary exam II |
| Category: | Nursing |
| Created by: | garrowcousino on 2006-02-26 |
| Stack ID: | 35501 |
| Flap 1 | Flap 2 |
| What is the ABCDE mnemonic r/o Malignancy? | A = Asymmetry of lesion (not regularly round or oval),B= Border irregularity,C= Color variation,D=Diameter >6mm (pencil eraser)E= Elevation and enlargement |
| A== | A = Asymmetry of lesion (not regularly round or oval) |
| B= | B= Border irregularity |
| C= | C= Color variation |
| D= E= | D=Diameter >6mm (pencil eraser)E= Elevation and enlargement |
| Primary skin lesions MACULE = | flat, nonpalpable, circimscribed, <1cm diamater, freckles =rubeolo & Rubella |
| circimscribed | Bounded by a line; limited or confined. |
| freckles | freckles =rubeolo & Rubella |
| Primary skin lesions Patch = | flat nonpalpalpable, a macule >1cm. in diameter |
| Primary Lesions Plaque | elevated, flat top, firm rough, a papule larger than o.5cm diameter, Psoriasis |
| Primary skin Lesions Papule | elevated firm, <0.5 cm, circimscribed border, solid mass, warts |
| Primary skin lesions Bulla= | >0.5 cm, elevated circumscribed, superficial, filled w/ serous fluid, contact dermatitis, posion ivy |
| Primary Skin Lesions Vesicle= | elevated, circumscribed, superficial, filled with serous fluid, <0.5 cm in diameter, blister varicella |
| Primary Lesions Tumor | >1-2 cm, elevated firm Palpable, deeper in dermis than Papule, irregular boarders |
| Primary Lesions Nodule | elevated firm Palpable deeper in dermis than papule, 5-2 cm in diameter, lymphoma |
| lymphoma | Any of various usually malignant tumors that arise in the lymph nodes or in other lymphoid tissue |
| Primary Lesions pustule | elevated superficial,similar to a vesicle but filled with purulent fluid ie acne, impetigo=A contagious bacterial skin infection, usually of children, that is characterized by the eruption of superficial pustules and the formation of thick yellow crusts, |
| Primary Lesions cyst | elevated , circumscribed, palpable, encapsulated, filled with liquid or semi solid material sabaeous cyst |
| superficial | Of, affecting, or being on or near the surface: a superficial wound. |
| < is an acronym for: | less than The "less than" symbol (<) is used to express a lower value. For example, if (x < 10) means "if X is less than 10." |
| > is an acronym for | Greater than The "greater than" symbol (>) is used to express a larger value. For example, if (x > 10) means "if X is more than 10." |
| purulent fluid | Containing, discharging, or causing the production of pus: a purulent infection. AKA pus A generally viscous, yellowish-white fluid formed in infected tissue, consisting of white blood cells, cellular debris, and necrotic tissue. |
| circumscribed | Bounded by a line; limited or confined. |
| Primary Lesions wheal | elevated mass, Irregular, serous fluid in the dermis, no fluid in a cavity, Urticaria, insect bites |
| Urticaria, = | (AKA = hives)A skin condition characterized by intensely itching welts and caused by an allergic reaction to internal or external agents, an infection, or a nervous condition. Also called nettle rash, urticaria. |
| Primary skin Lesions | Primary lesions are physical changes in the skin considered to be caused directly by the disease process. Types of primary lesions are rarely specific to a single disease entity. |
| Secondary skin Lesions | Secondary lesions may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process. The distinction between a primary and secondary lesion is not always clear. |
| Secondary Lesions erosion | loss of superficial epidermis, dermis not involved, depressed moist area, scratch marks |
| 2ndary lesions Ulcers = | skin loss past epidermis, neccrotic tissue loss,bleeding and scarring, Pressure ulcar |
| neccrotic /ne·crot'ic | Death of cells or tissues through injury or disease, especially in a localized area of the body. |
| 2ndary lesions scar | skin mark, replacement of connective tissue, new scars= red/purple old scars = white |
| Fissure | linear, may involve dermis, chapped lips, athlete's foot |
| linear | Of, relating to, or resembling a line; straight. Having only one dimension,In, of, describing, described by, or related to a straight line. |
| 2ndary lesions Crust | dried serum blood or purulent material, slightly elevated, varied size, scab, eczema |
| 2ndary lesions scale | flaky exfoliation, irregular, thick or thin, dry or oily, Psroiasis exfoliative dermatitis |
| 2ndary lesions keloid | hypertrophied scar tissue, elevated irregular, red, higher rate in African Americans, surigical incision |
| 2ndary lesions atrophy | transparent look of epidermis, loss of markings, vessels may be noted, aged skin arterial insufficiency |
| exfoliative dermatitis | Widespread dermatitis characterized by scaling and shedding of the skin and usually accompanied by redness. Also called pityriasis rubra, Wilson's disease. |
| @ndary Lesions Lichenification | thickening of skin, accentuated skin markings, repeated irritationThickening of the skin with hyperkeratosis caused by chronic inflammation resulting from prolonged scratching or irritation. |
| Vascular skin Lesions | Petechia,Hematoma,cherry angioma, spider angioma |
| Petechia, | A small purplish spot on a body surface, such as the skin or a mucous membrane, caused by a minute hemorrhage and often seen in typhus. |
| Hematoma | A localized swelling filled with blood resulting from a break in a blood vessel. |
| / spider angioma/ cherry angioma | Spider angiomas, also known as "nevus araneus," are found slightly below the skin's surface. They often contain a central red spot, and reddish extensions that radiate outward like a spider's web estrogen , pregnancy/Cherry angioma is the most common kind |
| ecchymosis | The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin. |
| Epidermis -protective barrier epidermis replaced every ??? | 4 weeks 1 pound shed a year |
| stratum germinativum-basal cell layer-forms ??? including ??? | new cells include the protein keratin and pigment producers-melanocytes |
| cells migrate from the basal layer to the ??? | stratum corneum-dead cells shedding |
| Dermis = | Inner supportive layer connective tissue- collagen, nerves, sensory preceptors, blood vessels, lymphatics, hair follicles, sebacious, sweat glands,= prevents tearing of skin elderly loss = skin tears |
| subcutaneous layer | adopose tissue, stores fat 4 energy, insulatation temp control |
| Epidermal appendages | Hair Hair Vestigial-no longer needed for protection from cold or trauma Threads of keratin |
| 2 types of hair and where found ? | Vellus hair-fine, over body Terminal hair-scalp, eyebrows, axillae, pubis,face chest in males |
| Sebaceous glands | Lipid substance-sebum-hair follicles Lubrication Abundant-face,, forehead,scalp, chin |
| Name the 2 types of sweat glands | Ecrine-dilute saline-sweat (mature in 2 month olds) Apocrine glands-thick milky secretions-open to hair follicles |
| where r Apocrine glands- found etc | Axillae, nipples,navel, anogenital area Active during puberty Bacterial flora react with apocrine sweat to produce musky body odor Function decreases with age |
| anogenital area | Relating to the anus and the genitals. |
| name 10 functions of the skin | Protection from dehydration and minor trauma Temperature control, absorption,excretionSensory input about the environment First line of defense vs penetration Expression of emotion Sweating Production of Vitamin D Wound repair Identification Communication |
| Name *8 subjective findings related to the skin | 1Previous history of skin disease 2Change in pigmentation 3Change in moles 4Excessive dryness or moisture 5Pruritus-most common skin symptom (can + diabitis)6Excessive bruising 7Rash or lesion 8MEDICATIONS and ALLERGIES (photosensivity hives) |
| Name 4 subjective findings related to the skin | 1Hair loss 2Change in nails 3Environmental or occupational hazards exposure to irrantants4Self-care behavior |
| what are some questions u might ask while taking a health history ???Why? | 1Has skin changed with age 2Trouble clipping nails 3Multiple bruises Delayed wound healing (diabiates circulation)Itching Pain Skin care |
| Problem based history | Rash Pain/Discomfort to the skin Itching and hives Change in skin color or moles Hair Nails |
| Risk factors concerning the skin include??? | Systemic disease (lupus)Previous trauma or injury Infection Immobility Frequent sun exposure Exposure to chemicals Exposure to allergens Medications with photosensitivity |
| Equiptment needed to assess the skin? | Magnifying lens Centimeter ruler Light source Gloves |
| Inspection of color cyanosis will present __ in light skin and in dark skin | cyanosis light = grayish blue tone dark = ashen gray |
| cyanosis | A bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. |
| Inspection of color Ecchymosis will present in light skin and in dark skin | light skin= Dark red, purple/ dark skin = deeper blue or black |
| Ecchymosis | Brusing (AKA) The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin. |
| Inspection of color Jaundice will present in light skin and in dark skin | light skin= yellowish dark skin =yellow green inside of eyelid or mouth |
| Jaundice | Yellowish discoloration of the whites of the eyes, skin, and mucous membranes caused by deposition of bile salts in these tissues. It occurs as a symptom of various diseases, such as hepatitis, that affect the processing of bile. |
| Inspection of color Pallor will present in light skin and in dark skin | in light skin = white in dark skin= lighter than nl |
| Pallor | Extreme or unnatural paleness. |
| in light skin and Petechiae in dark skin | light = SM pinpoints Dark = difficult 2 see |
| Petechiae | A small purplish spot on a body surface, such as the skin or a mucous membrane, caused by a minute hemorrhage and often seen in typhus. |
| Inspection of color Rash will present in light skin and in dark skin | light seen & palpate dark = palpate |
| Rash | (blank) |
| Inspection of color scar will present in light skin and in dark skin | light= narrow line dark = keloid |
| Inspection of color erythema will present in light skin and in dark skin | light =red& warm dark = hard to see feel warm |
| erythema | Redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection. |
| 7 Lesion Characteristics | 1Location & distribution 2Color-vitiligo-pg 231 3Pattern 4Edges 5Flat, raised, sunken 6Size 7 Characteristics |
| what are 4 different shapes of skin lesions? | 1Singular/discrete 2Groups/clustered-3Polycyclic-annular lesion group-4Confluent-runs together-5Linear 6Zosteriform 7Generalized |
| Name 7 different patterns of skin lesions | 1Singular/discrete2Groups/clustered-3Polycyclic-annular lesion group-psoriasis |
| 1Singular/discrete example of | -molluscum |
| molluscum | Any of various skin diseases in which soft spherical tumors form on the face or other part of the body. |
| 2Groups/clustered-example of | contact dermatitis |
| contact dermatitis | An acute or chronic skin inflammation resulting from contact with an irritating substance or allergen. |
| 3Polycyclic-annular lesion group-psoriasis | psoriasis |
| psoriasis | A noncontagious inflammatory skin disease characterized by recurring reddish patches covered with silvery scales. |
| Polycyclic-annular lesion group- | Shape: Round, oval, polycyclic, annular. 4. Arrangement: Zosteriform, arciform, |
| 4Confluent-runs together- | urticaria |
| urticaria | aka hives A skin condition characterized by intensely itching welts and caused by an allergic reaction to internal or external agents, an infection, or a nervous condition. |
| 5Linear- example | scratch, streak, stripe |
| 6Zosteriform- example | linear arrangement along nerve route Zoster |
| Zoster | eruptions along a nerve path often accompanied by severe neuralgia |
| 7Generalized-example | over most of body |
| What is noted while palpating during a skin assessment? | Turgor-elasticity Moisture Temperature Mobility- tenting Texture Thickness Edema |
| What should be noted about the hair during a skin hair and nail assessment? | Head, axillary, pubic, facial, body Scalp and hair-inspect for surface characteristics, hair distribution, texture, quantity, and color Facial & body hair-inspect for hair distribution, quantity, and texture. Hirsutism-excess body hair-think endo in femal |
| Hirsutism | -excess body hair-think endo in female |
| how are the assessed? | Inspect & palpate |
| What is noted about the nails in a nail assessment? | Shape-profile sign Contour-profile sign Consistency-smooth,regular Color Thickness-uniform Cleanliness Cap refill TOES—foot care? |
| What are some normal findings in an older adult that could be found ina hair, skin, nails assessment? | Skin is dryer, less perspiration-xerosis Folded and wrinkled appearance, itchy skin loose flaky Decrease in melanin production Age associated baldness Slower nail growth |
| normal findinds concerning skin Texture in older adults | Acrochordons,Senile lentigines-liver spots-keratosis Seborrheic,Actinic keratosis, keratosis |
| Acrochordons | - skin tags-eyelids cheeks, neck axillae, trunk |
| Senile lentigines | Senile lentigines-liver spots-extensive sun exposure-forearms, dorsa of hands |
| Keratoses- | raised thick crusty scaly warty |
| Seborrheic keratosis | -dark greasy-sun exposure |
| Actinic keratosis | -red-tan,plaque- silvery white scale adhered to plaque-r/t sun exposure-PREMALIGNANT-may becone squamous cell cancer |
| Changes in the skin in older adults | Thickness Thin-parchment-subcutaneous fat diminishes Mobility, turgor Less elasticity-tenting |
| changes in hair in older adults | Growth decreases Post menopause-women bristly hairs chin upper lip Men- hair bristly hair ears,nose,eyebrows Male pattern baldness-inherited Hair turns gray-decrease of melanocytes |
| Changes in Nails in older adults ? | growth rate decreases Surface brittle,peeling yellowed Toenails thick misshapen Fungal infection-thick crumbling, erythematous scaling of contiguous skin surfaces |
| other changes in the kin in older adults | Mongolian spots Café au lait spot 6+ neurofibromatosis Erythema toxicum-newborn Acrocyanosis Physiological jaundice Carotenemia Milia Lanugo |
| Mongolian spots | Any of a number of dark-bluish or mulberry-colored spots on the lower back, observed in newborn infants, that enlarge for a short time after birth and then gradually recede. Also called blue spot. |
| Café au lait spot 6+ neurofibromatosis | look up |
| Acrocyanosis | A circulatory disorder in which the hands, and less commonly the feet, are persistently cold, blue, and sweaty. |
| Physiological jaundice | look up Mild jaundice of newborns caused mainly by functional immaturity of the liver. Also called physiologic icterus. |
| Carotenemia | The presence of excess carotene in the blood, often resulting in yellowing of the skin. |
| Milia | milk spots White plaques of hyalinized fibrous tissue situated in the epicardium and overlying the right ventricle of the heart where not covered by lung. |
| Lanugo | A covering of fine, soft hair, as on a leaf, an insect, or a newborn child. |
| start @ stages of preassure ulcar | (blank) |
| Stages of preassure ulcers Stage 1= | skin unbroken appears red |
| Stages of preassure ulcers Stage 2 | skin brokensuperficial skin loss involving epidermis or dermis lesion vesical or blister |
| Stages of preassure ulcers Stage 3 | involves epidermis dermis and sub q tissue crater not into fascil |
| Stages of preassure ulcers Stage 4 | involves open dermis & sub Q bone & other tissue |
| variations | Limited mobility Risk for skin breakdown Stages of skin breakdown Bony prominences |
| Health Promotion | Immunizations Sun exposure and protection Skin cancer Basal cell carcinoma Melanoma |
| Basal cell carcinoma | blistered crusty lesions |
| squamous | crater indentation |
| Skin self evaluation Pg238 | know this |
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1 UNIT 10 Integumentary 2 SKINEpidermis-protective barrier Stratum germinativum-basal cell layer-forms new cells-include the protein keratin, and pigment producers-melanocytes Cells migrate from the basal layer to the stratum corneum- dead cells-shedding Epidermis replaced every four weeks 1 pound shed per year. 3 Skin 2Dermis Inner supportive layer-connective tissue-collagen Nerves Sensory perceptors Blood vessels Lymphatics Hair follicles Sebaceous Sweat glands 4 Skin 3Subcutaneous layer Adipose tissue Stores fat for energy Insulation Temp control 5 Skin 4Epidermal appendages Hair Vestigial-no longer needed for protection from cold or trauma Threads of keratin Two types Vellus hair-fine, over body Terminal hair-scalp, eyebrows, axillae, pubis,face chest in males 6 SKIN 5Sebaceous glands Lipid substance-sebum-hair follicles Lubrication Abundant-face,, forehead,scalp, chin 7 SKIN 5Sweat glands Ecrine-dilute saline-sweat (mature in 2 month olds) Apocrine glands-thick milky secretions-open to hair follicles Axillae, nipples,navel, anogenital area Active during puberty Bacterial flora react with apocrine sweat to produce musky body odor Function decreases with age 8 Functions of skinProtection from dehydration and minor trauma Temperature control, absorption,excretion Sensory input about the environment First line of defense vs penetration Expression of emotion Sweating Production of Vitamin D Wound repair Identification Communication-blushing blanching 9 Subjective infoPrevious history of skin disease Change in pigmentation Change in moles Excessive dryness or moisture Pruritus-most common skin symptom Excessive bruising Rash or lesion MEDICATIONS and ALLERGIES 10 Subjective cont.Hair loss Change in nails Environmental or occupational hazards Self-care behavior 11 Health HistoryHas skin changed with age Trouble clipping nails Multiple bruises Delayed wound healing Itching Pain Skin care 12 Problem-Based HistoryRash Pain/Discomfort to the skin Itching and hives Change in skin color or moles Hair Nails 13 Risk factorsSystemic disease Previous trauma or injury Infection Immobility Frequent sun exposure Exposure to chemicals Exposure to allergens Medications with photosensitivity 14 EquipmentMagnifying lens Centimeter ruler Light source Gloves 15 Inspection of color Light Dark 16 Lesion CharacteristicsLocation & distribution Color-vitiligo-pg 231 Pattern Edges Flat, raised, sunken Size Characteristics 17 ShapesRound/oval Annular-circular starts in center, spreads Target-Lyme disease Gyrate- twisted coiled Pg 250-251 18 PatternsSingular/discrete-molluscum Groups/clustered-contact dermatitis Polycyclic-annular lesion group-psoriasis Confluent-runs together-urticaria Linear-scratch, streak, stripe Zosteriform-linear arrangement along nerve route Zoster Generalized-over most of body 19 PalpationTurgor-elasticity Moisture Temperature Mobility- tenting Texture Thickness Edema 20 HairHead, axillary, pubic, facial, body Scalp and hair-inspect for surface characteristics, hair distribution, texture, quantity, and color Facial & body hair-inspect for hair distribution, quantity, and texture. Hirsutism-excess body hair-think endo in female 21 NailsInspect & palpate Shape-profile sign Contour-profile sign Consistency-smooth,regular Color Thickness-uniform Cleanliness Cap refill TOES—foot care? 22 Examination Older AdultsSkin is dryer, less perspiration-xerosis Folded and wrinkled appearance, itchy skin loose flaky Decrease in melanin production Age associated baldness Slower nail growth 23 Older Adults 2Texture Acrochordons- skin tags-eyelids cheeks, neck axillae, trunk Senile lentigines-liver spots-extensive sun exposure-forearms, dorsa of hands Keratoses-raised thick crusty scaly warty Seborrheic keratosis-dark greasy-sun exposure Actinic keratosis-red-tan,plaque- silvery white scale adhered to plaque-r/t sun exposure-PREMALIGNANT-may becone squamous cell cancer 24 Older Adult 3Thickness Thin-parchment-subcutaneous fat diminishes Mobility, turgor Less elasticity-tenting 25 Older Adult 4Hair Growth decreases Post menopause-women bristly hairs chin upper lip Men- hair bristly hair ears,nose,eyebrows Male pattern baldness-inherited Hair turns gray-decrease of melanocytes 26 Older Adult 5Nails growth rate decreases Surface brittle,peeling yellowed Toenails thick misshapen Fungal infection-thick crumbling, erythematous scaling of contiguous skin surfaces 27 AdditionalMongolian spots Café au lait spot 6+ neurofibromatosis Erythema toxicum-newborn Acrocyanosis Physiological jaundice Carotenemia Milia Lanugo 28 VariationsLimited mobility Risk for skin breakdown Stages of skin breakdown Bony prominences 29 Health PromotionImmunizations Sun exposure and protection Skin cancer Basal cell carcinoma Melanoma Skin self evaluation pg-238-know this 30 ABCDE mnemonic r/o MalignancyA=Asymmetry of lesion ( not regularly round or oval) B=Border irregularity C=Color variation D=Diameter >6mm (pencil eraser) E=Elevation and enlargement |
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