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24 Cards in this Set
- Front
- Back
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What makes up the integumentary system?
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skin
hair nails |
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What are the 3 layers of the skin from outermost to innermost?
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epidermis
dermis subcutaneous |
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Which aspects are involved in assessment of the skin (inspection, palpation, percussion, and/or auscultation)?
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Inspection
Palpation |
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What is included in the subjective assessment of the skin?
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Past history of skin disorders?
Changes in skin color? Changes in a mole? Excessive dryness, or moisture? Pruritis? Excessive bruising? Rash or lesion? Medications? Environmental hazards-- work, sun, insects, plants Self care- cosmetics, soaps, etc |
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What equipment is needed for the objective assessment of the skin?
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strong, direct lighting
small centimeter ruler penlight gloves |
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When assessing the skin, what part of the body should you begin with and why?
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The hands because it is nonthreatening
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When inspecting the skin, what are you observing?
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color
pigmentations: freckles, nevus (mole), birthmarks |
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When palpating the skin, what are you assessing for?
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Temperature
Texture Moisture Edema Turgor Bruising |
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Are cherry angiomas a normal finding?
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Cherry angiomas are common in adults over 30-- not a significant finding
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What is ecchymosis?
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a bruise
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What is cellulitis?
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Infection underneath the skin, often from a break in the skin
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What could cause gangrene?
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diabetes, circulatory problems, etc
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What should be assessed if a lesion is identified?
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Color
Shape Size in cm Elevation (flat or raised) Location and distribution on body Exudate (color, odor) |
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What should you know and educate your patients about skin cancer?
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The centers for disease control and preventioncategorizes skin cancer as an epidemic
Skin cancer is the most common cancer and more than one million cases are diagnosed each year in this country The most common form of cancer in the U.S. Persons diagnosed with melanoma has doubled in the past 30 years Melanoma is the deadliest skin cancer and is preventable, since 90% of melanomas are caused by UV light or sunlight Contributions to the increase in skin cancers are: -the depleting ozone layer -change in leisure activities (more beach vacations) -tanning salons |
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What are the 3 types of skin cancer?
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Basal cell
squamous cell melanoma |
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What is the nurses role in skin cancer?
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Nurses need to regularly reinforce education to impact behavior
If nurses can increase the community's knowledge and change tanning behaviors, nurses can decrease rates of skin cancer through the nurses' role of advocacy and education, nurses can have a significant impact in decreasing the epidemic of skin cancer |
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What are the guidelines for teaching sun safety measures?
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Seek shade, avoid sun between 10a-4p when UV rays are strongest
Cover up skin with clothing, wide brimmed hat (4" brim), which shades head and neck Avoid tanning beds There is no such thing as a safe or healthy tan |
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What should be known about sunscreen?
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Use at least SPF 15
Apply 1/2 hour before sun exposure Re-apply every 2 hours Re-apply after swimming or sweating Wear sunglasses, with 100% UVA protection. Sunglasses act as sunscreen for your eyes. |
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What is involved in the patient education of skin self exams (SSE)?
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SSE monthly, full length mirror
learn what moles, blemishes, birth marks look like, so you know when changes occur Using photos can assist in noting changes Examine for any changes: -new mole change in mole color, shape, size, texture -Sore that doesn't heal Check all skin surfaces: scalp, use blow dryer to assist looking at scalp Examine between fingers, toes, soles of feet Examine all skin surfaces using hand held and full length mirror Have family member assist |
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What are the danger signs of pigmented lesions (moles)?
hint...abcde |
A- asymmetrical shape
B- border irregularity C- color D- diameter greater than 6 mm E- elevation (flat or raised) |
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What are important health promotion aspects to educate the client on concerning skin care?
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Teach all adults to examine skin once a month & a yearly exam by dermatologist
Teach diabetics the importance of skin care to feet |
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What is involved in the assessment of the hair?
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Inspection and palpation
Color Texture Distribution Lesions of scalp |
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What determines the color of hair?
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melanin production
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What is involved in the assessment of nails?
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Shape and contour: slightly curved or flat and smooth, 160 degrees
Consistency: surface smooth and regular, not brittle or splitting, uniform thickness Capillary refill: depress nailbed color blanches, color should return in less than 1-2 seconds |
