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52 Cards in this Set
- Front
- Back
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Erythema
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Redding of the skin; caused by blushing, fever, inflammation, hypertension
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Cyanosis
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Bluish discoloration of the skin and mucous membranes; results from poor oxygenation of hemoglobin, lack of adequate RBCs or hemoglobin
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Pallor
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paleness of the skin; caused by shock, fear, anemia, anger or hpoxia
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Jaundice
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yellowing-to-orange color visible in the skin and mucous membranes
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Epidermis
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*Protects tissue from physical, chemical and biologic damage.*Prevents water loss and severs as a water-repellent layer. * Stores melanin, which protects tissues from harmful effects of the ultraviolet radiation in sunlight. *Converts cholesterrol molecules to vitamin D when exposed to sunlight. * Contains phagocytes, which prevent bacteria from penetrating the skin
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Dermis
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*Regulates body emperature by dilating and constricting capillaries. Transmits messages via nerve endings to the central nervous system
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Sebaceous (oil) glands
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secrete sebum, which lubricates skin and hair and plays a role in killing bacteria
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Eccrine sweat glands
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regulate body heat by excretion of perspiration
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Apocrine sweat glands
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unknown function
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Hair
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cushions the scalp. eyelashes and cilia protect the body from foreign particles. provides insulation in cold weather
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Nails
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Protect the fingers and toes, aid in grasping, and allow for various other activities, such as scratching the skin, picking up small items, peeling an orange.
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if a client has a skin problem
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identify its onset, characteristics, course, and severity, ask about any change in health, skin color changes
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Skin Assessment
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O- onset
P- provocation/palliation Q- quality/quantity R- region S- severity T- time |
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Nail Assessment
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Clubbing, Paronchychia (infection), White nail syndrome (calcium, anemia, arsenic poisoning), Psoriasis
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Skin Lesions
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Bleb; Bulla; Crust; Excoriation; Fissure; Cyst; Macule; Nodule; Papule; Pustule; Scale; Scar; Ulcer; Vesicle; Wheal; Keloid
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Macule, Patch
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Flat, nonpalpable change in skin color. small than 1 cm, with circumscribed border, and patches are larger than 1 cm may have an irregular border
I.E.: Macules: freckles, measles, and petechiae. Patches: mongolian spots, port-wine stains, vitiligo, and chloasma |
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Vesicle, Bulla
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Elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders. Vesicles are smaller than 0.5cm; bullae are larger than 0.5cm
I.E.: Vesicles: herpes simplex/zoster, early chickenpox, poison ivy, and small bun blisters. Bullae: contact dermatitis, friction blisters, and large burn blisters |
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Papule, Plaque
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Elevated, soild, palpable mass with circumscribed border. Papules are smallerr than 0.5cm; plaques are groups of papules that form lesions larger than 0.5cm
I.E.: Papules: eleveated moles, warts, and lichen planus. Plaques: psoriasis, actinic keratosis, and also lichen planus |
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Wheal
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Elevated, often reddish area with iregular border caused by diffuse fluid in tissues rather than free fluid in a cavity, as in vesicles. size varies.
I.E: insect bites and hives |
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Nodule, Tumor
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Elevated, soild, hard or soft papable mass extending deeper into the dermis than a papule. Nosules have circumscribed borders and are 0.5-2cm; tumors may have irregular borders and are larger than 2cm
I.E.: Nodules: small ipoma, squamous cell carcinoma, fibroma, and intradermal nevi. Tumors: large lipoma, carcinoma, and hemangioma |
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Pustule
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Elevated, pus-filled vesicle or bulla with circumscribed border. size varies
I.E. Acne, impetigo, and carbuncles (large boils) |
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Cyst
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Elevated, encapsulated, fluid-filled, or semisolid mass originating in the subcutaneous tissue or dermis, usually 1 cm or larger.
I.E. varieties include sebaceous cysts and epidermoid cysts |
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Crust
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Dry blood, serum, or pus left on the skin surface when vesicles or pustules burst. can be red-brown, orange or yellow, large crusts that adhere to the skin surface are called scabs.
I.E.: Eczema, impetigo, herpes, or scabs after abrasion |
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Atrophy
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A translucent, dry, paper-like sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin.
I.E. Striae, aged skin |
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Ulcer
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Deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. may bleed. may leave scar
I.E.: Decubitus ulcers (pressure sores), stasis ulcers, chancres |
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Erosion
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Wearing away of the superficial epidermis causing a moist, shallow depression. because erosions do not extend into the dermis, they heal without scarring.
I.E.: scratch marks, ruptured vesicles |
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Fissure
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Linear crack with sharp edges, extending into the dermis
I.E.: cracks at the corners of the mouth or in the hands, athlete's foot |
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Lichenification
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rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing.
I.E.: chronic dermatitis |
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Scales
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Shedding flakes of geasy, keratinized skin tissue. color may be white, gray or silver. Texture may vary from fine to thick
I.E.: Dry skin, dandruff, psoriasis, eczema |
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Keloid
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Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. extends beyond the site of the original injury. higher incidence in people of African descent
I.E.: keloid from ear piercing or surgery |
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Pruitus
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*Itching sensation producing the urge to scratch *small or wisdespread with or without a rash *Triggered by heat and prostaglandins *increased by release of histamine and chemical mediators
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Dermatititis
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*Acute or chronic inflammation of the skin *Erythema and pain or Pruritis *Vesicles, scales, and pruritis initially *Progresses to edema, serous discharge, and crusting (eczema, posion ivy; use steroids from neck dwn)
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Acne
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Disorder of sebaceous glands (face, scalp, scrotum) *sebum is produced in response to hormonal stimulation *Lesions are called comedones *Acne vulgaris= teenagers *Acne rosacea= later in life
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Cellulitis
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infection of skin and underlying tissues * usually staph or strep * presents with localized inflammation * Erythema, pain, tenderness, warmth, fever (useally in lower limbs)
DVT vs. Cellulitis: history of onset |
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Impetigo
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Causative agent: staph A or strep. *Contagious! * honey colored crusted lesions/ purulent drainage * Dx: culture * Rx: anti-infective therapy * Patient teaching: hygine
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Herpes Simplex
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Self-limiting; no cure
*Type 1: cold sore on lip *Type 2: sexually trnsmitted-genitalia *lays dorment untill stressed, follows nerve ganlia; Dx: culture of liseions, Rx: supportive (acyclovir,zovirax decrease severity of outbreak; analgesic, anti-anxiety supportive) |
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Herpes Zoster
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shingles
*inflammation along spinal ganglia *along one side * dormant untill resistance lowered *contagious untill all blisters are crusted over *can be left with pain for months after *Vaccine: zostervax |
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Skin Malignancies
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A= (not) asymmetrical
B=(Irregular) Boarders C= color- uneven or irregular D=Diameter or size change (greater than 6mm) E=Eleveated surface area |
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Pressure Ulcers
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Microthrombi impede blood flow, resulting in ischemia and hypoxia * cells and tissue die and become necrotic
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Pressure Ulcers
Nursing care Assessment |
* identify pt. at risk * ddescribe appearance *Meause size and depth *minimize risk *conduct systematic inspection *keep skin clean and manage incontinaence *minimize environmental factors *minimize friction and shearing forces
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Pressure Ulcers
Nursing Care |
*maintain adequate nutritional intake * Maintain activity level *Teach client to shift weight * Use positioning devices, pillows * keep head of bed at lowest position * use specialty devices
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Burns
Assessment |
*Depth *extent *location * complicating factors * Burn exceeding 50% of TBS (total body surface) either superficial or deep is grave and potentially fatal
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Burn Types
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Thermal (Dry heat:flame, moist head: steam or hot liquid)
Chemical (acid or alkali) Electrical Radiation |
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Degree of burns
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Superficail
Partial thickness Full thickness |
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Rule of Nines
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Estimate palm = 1% of burn
fu7ll depth of burn may not be evident for several hours |
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Burn
Pathophysiology |
Tissue destruction can lead to: Fluid/protein losses, sepsis, Multiple system disturbances (metabolic, edocrine, respiratory, cardiac, hematologic, immune)
*Capillaries dilate: hyperpermeability X24hr *cell permeability= shift to interstial space * Hypovolemic shock is possible |
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Burns
Vascular changes |
Fluid shift
Periods of inflammatory response, vessels adjacent to burn injury dilate- increase capillar hydrostatic pressure and increse capillary permeability, continous leak of plasma from intravascular space into interstitial space, associated imbalances of fluid, electrolytes and acid-base occur, hemoconcentration, lasts 24-36hrs |
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Burns
System changes Cardiac |
* decreased cardiac output
*Need fluid resuscitation and suport with 02 |
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Burns
System changes Pulmonary |
*respiratioy insufficiency as secondary process
*Can progress to respiratory failure *Aggressive pulmonary toilet(flushing) and oxygenation |
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Burns
System changes Gastrointestinal |
* Decreased or absent motility (may need NG tube) * Curling's ulcer formation (stress) * h2 histamine blockers, mucoprotectants and enteral nutrition *Paralytic ileus
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Burns
System changes Metabolic |
*hypermetabolic state: Increased oxygen and calorie requirements, increase in core body temperature
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Burns
System changes Immunologic |
*Loss of protective barrier * Increased risk of infection * Suppression of humoral and cell-mediated immune responses
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