Skin & Respiratory Assessment

Front 1

Skin

Back 1

Largest Organ in the body. First line of defense. Nursing problems include: Infection, fluid & electrolyte imbalance, nutritional deficits, and tissue alterations.

Front 2

Epidermis

Back 2

This layer is made of skin cells at the end of their life-cycle. These cells provide protection from injury and a barrier to keep infectious organisms at bay. Think of this layer as the mulch covering the flowerbed. The epidermis holds in fluid and protects raw nerve cells from too much stimulation.

Front 3

Dermis

Back 3

The top soil. This layer contains capillaries that feed the cells with nutrient-rich blood. Just like top soil, most things grow here - including hair follicles, nerve cells, and sweat glands. If damaged, the dermis will weep serous fluid and swell.

Front 4

Subcutaneous

Back 4

This layer is also known as the hypodermis, and it is technically not officially skin, but rather attaches the skin to everything beneath. It also contains a layer of fat. Some of use have more fat than others, but this layer is always present in some form. In the flower bed, this is the layer of sand foundation that allows for drainage. Indeed, blood vessels in the subcutaneous layer feed and drain the capillaries of the dermis.

Front 5

5 Major Functions of the skin

Back 5

Protection against disease (It acts as a first defense against disease causing particles, due to the fact most can get through unopened skin).

Sensory response (specialized nerve cells sense and relay info to the brain).

Formation of Vitamin D (formed by ultraviolet light in fat molecules in your epidermis).

Maintaining body temperature (blood vessels in the skin can help to hod or release heat maintaining a constant temperature)

Waste exchange (sweat glands in the skin release waste in the sweat)

Front 6

Interactions with other body systems

Back 6

Putting the data together: why we do skin assessments!

Respiratory system, cardiovascular system, gastrointestinal system, urinary system, neurological system, endocrine system, lymphatic/immune system.

Front 7

Cyanosis

Back 7

Central and Peripheral Cyanosis. Not getting enough oxygen to the nail bed. You can check this to see how well the oxygen is getting to the extremities.

Front 8

Cardiovascular

Back 8

Altered Perfusion. Poor circulation. The dermis is not getting the blood supply that it needs and cannot feed the tissue. You can get an arterial ulcer. The toes can become necrotic. The tissue is dying and if not removed, gangrene can move in.

Front 9

Xanthelasma

Back 9

A localized cholesterol deposit beneath the skin and expecially beneath the eyelids - is a common manifestation of hypercholesterolemia. Lipid deposits that are not being excreted by the liver.

Front 10

Spider angiomas (Spider nevi)

Back 10

Collections of dilated blood vessels near the surface of the skin. They appear as slightly raised, small, reddish spots from which fine lines radiate outward, giving them a spider-like appearance. Can occur anywhere. Blood vessels are dilated because of pressure.

Front 11

The Urinary System

Back 11

Related to decrease ability to excrete toxins

Front 12

Neurological System

Back 12

Changes related to autonomic nervous system. There are changes in: Touch, temperature, pressure, pain

Front 13

ANS

Back 13

Controls the skin's blood vessels and glades results in changes in moisture and temperature

Front 14

Endocrine system

Back 14

Diabetes- ulcerations.

Front 15

Hypo or hyperthyroidism

Back 15

Hypo- dryness (hair becomes brittle)

Hyper- increased moisture (oily hair)

Front 16

Adrenal disease

Back 16

Adrenal gland produces stress hormones. Darkening of the skin.

Front 17

Breakout- Diabetes and Skin Related Changes

Back 17

Diabetes can affect every part of the body, including the skin. Skin problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early. Some of the problems are skin conditions anyone can have, but people with diabetes get more easily. These include bacterial infections, fungal infections and itching. Other skin problems happen mostly or only to people with diabetes. These include diabetic dermopathy disease of the skinX, necrobiosis lipidica diabeticoruma skin condition usually on the lower part of the legs. Lesions can be small or extend over a large area. They are usually raised, yellow, and waxy in appearance and often have a purple border. X, diabetic blisters, and eruptive xanthomatosis.

Front 18

Diabetes: Bacterial infections

Back 18

Styes (infections of the glands of the eyelid)

Bois Folliculitis (infections of the hair follicles)

Carbuncles (deep infections of the skin and the tissue underneath.

Infections around the nails, inflamed tissues that are usually hot, swollen, red, and painful.

Several different organisms can cause infection, the most common being Staphylococcus bacteria.

Front 19

Diabetes: Fungal Infections

Back 19

The culprit in fungal infections of people with diabetes is often Candida albicans. This yeast-like fungus can create itchy rashes of mosit, red areas surrounded by tiny blister and scaled. The infections often occur in war, mosit folds of the skin. Problem areas are under the breasts, aound the nails, between fingers and toes, in the corners of the mouth, under the foreskin, and in the armpits and groin. Common fungal infections include: jock itch, athlete's foot, ringworm (a ring-shaped itchy patch), and vaginal infection that causes itching.

Front 20

Diabetes: Itching

Back 20

Localized Itching is often caused by diabetes. It can be caused by a yeast infection, dry skin, or poor circulation. When poor circulation, the flow of blood through the body's blood vessels and Heart. X is the cause of itching, the itchies areas may be the lower parts of the legs. You may be able to treat itching yourself. Limit how oftern you bathe, particularly when the humidity is low. Use mild soap with moisturizer and apply skin cream after bathing.

Front 21

Velvet Plaques

Back 21

Velvety plaques in the neck and/or armpit suggest diabetes. This condition- acanthosis nigricans- could be benign or be caused by obesity. But, it is very often a sign of diabetes. In rare cases, acanthosis nigricans occurring in other places, like the hands or lips and they may indicate an internal cancer.

Front 22

Acanthosis Nigricans

Back 22

A condition in which tan or brown raised areas appear on the sides of the neck, armpits, and groin. They can also occur on the hands, elbows, and knees.

Front 23

Diabetic Dermopathy

Back 23

Known as shin spots which are caused as result of changes to the blood vessels which supply the skin. Dermopthy look like shiny oval or round lesions on the skin which is thin. Found on lower front parts of the lower leg. Diabetes can cause changes in the small blood vesselstubes that carry blood to and from all parts of the body. The 3 main types of blood vessels are arteris, veins, and capillaries. X. These changes can cause skin problems called diabetic dermopathy. Dermopathy often looks like light brown, scaly patches. These patches may be oval or circular. Some people

mistake them for age spots. This disorder most often occurs on the front of both legs.

Front 24

Necrobiosis Lipoidica Diabeticorum (NLD)

Back 24

Changes in collagen and fat content beneath. The skin cause this problem. Skin becomes reddened and thinned. Problems are found on parts of the lower legs and can ulcerate. Often is painful and itchy. Disease that may be caused by changes in the blood vessels is necrobiosis lipoidica diabetucorum (NLD). NLD causes spots similar to diabetic dermopathy, but they are fewer, larger, and deeper. NLD often starts as a dull, red, raised area. After a while, it looks like a shiny scar with a violet border. The blood vessels under the skin may become easier to see. Sometime NLD is itchy and painful. Sometimes the spots crack open.

Front 25

Digital Sclerosis

Back 25

Condition where skin on the fingers, toes, and hands turn waxy, thick, and tight. A stiffness of the joints of the finger can also occur. Moisturizers and lotions can help with softening the skin.

Front 26

Immune System

Back 26

Skin is a protective barrier, therefore, the more breaks in the skin = increase risk of infection. Think about the number of access sites patients usually has. Allergic Reaction: Psoriasis, Dermitis, Lupus erythematosus.

Front 27

Health History

Back 27

Changes in skin, hair, and nails

Mole/lesions, pruritus, rashes

Allergies

Medical condition (diabetes, thyroid, liver, heart)

Exposure to infectious/contagious illness

Medications

Family History (skin cancer)

Psychosocial profile

Review of systems

Front 28

Inspection & Palpation

Back 28

Color, temperature, moisture, turgor, texture, odor, hair, nails (clubbing, infections).

Use the back part of you hands to feel for more sensitivity.

Front 29

Lesions

Back 29

Circumscribed areas of pathologically altered tissue.

Described by patterns and configuration. Discrete, confluent, circular, linear.

Described by distribution. Diffuse, scattered, localized, regional, dermatone.

Described by size, shape, elevation, depression

Front 30

Primary Lesions

Back 30

Lesions present at the initial onset of the disease

Front 31

Secondary lesions

Back 31

Lesions that are the result of changes over time caused by disease progression, manipulation (scratching, rubbing, picking) or treatments.

Front 32

Scale

Back 32

heaped-up keratinized cells; flaky exfoliation; irregular; thick or thin; dry or oily; variable size; silver, white, or tan in color.

Examples: psoriasis

Front 33

Crust

Back 33

Dried serum, blood or purulent exudate; slightly elevated; size variable.

Examples: impetigo discoid pattern atopic eczema

Front 34

Excoriation

Back 34

loss of epidermis; linear area usually due to scratching.

Example: atopic eczema

Front 35

Lichenification

Back 35

Rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching.

Examples: chronic eczema, lichen simplex

Front 36

Macule

Back 36

A flat mark; circumscribed area of color change: brown, red, white or tan

Example: vitiligo

Front 37

Papule

Back 37

Elevated 'spot'; palpable, firm, circumscribed lesion generally less than 5 mm in diameter.

Example: scabies/insect bites

Front 38

Nodule

Back 38

Elevated; firm; circumscribed; plapable; can involve all layers of the skin; larger than 5 mm in diameter

Example: erythema nodosum

Front 39

Plaque

Back 39

Elevated, flat, topped, firm, rough, superficial papule greater than 2 cm in diameter. Papules can coalesce to form plaques.

Example: psoriasis

Front 40

Wheal

Back 40

Elevated, irregular-shaped area of cutaneous oedema; solid transient, changing, variable diameter; red, pale pink or white in color.

Example: urticaria

Front 41

Vesicle

Back 41

elevated, circumscribed, superficial fluid filled blister less than 5 mm in diameter.

Example: Herpes simplex/pompholyx

Front 42

Bulla

Back 42

Vesicle greater than 5 mm in diameter.

Example: bullous pephigoid

Front 43

Pustule

Back 43

Eleated, superficial, similar to vesicle but filled with pus.

Example: impetigo

Front 44

ABCDE Warning Signs

Back 44

A- asymmetry

B- border irregularity

C- color variation

D- diameter >6mm

E- elevation (controversial)

Front 45

Pressure Ulcer Risk factors

Back 45

Impaired mental status, impaired nutritional status, sensory deficits, immobility, mechanical force, shearing and friction, increased temperature, excessive exposure to moisture, excessive exposure to moisture.

Front 46

Structures of Respiratory Symstem

Back 46

Nasal cavity, pharynx, larynx, trachea, main stem bronchus, bronchioles, alveolar ducts, alveolar sacs, pleura (parietal/visceral)

Front 47

Medulla Oblongata & Pons

Back 47

Respiratory center of the brain

Front 48

Medulla Oblongata

Back 48

Motor function of breathing, controls diaphragm movement

Front 49

Pons

Back 49

Responsible for rhythm of breathing

Front 50

Take into consideration. . .

Back 50

Traumatic brain injuries and increased intracranial pressure

Front 51

Bronchial circulation

Back 51

Attends to metabolic demands of the lung

Front 52

Pulmonary Circulation

Back 52

Fosters the exchange of gases between alveoli and the blood in the pulmonary capillaries

Front 53

Diaphragm and Accessory Muscles

Back 53

Accessory muscles enhance ventilation by increasing chest expansion and lung size during inspiration.

Internal and External intercostal muscles

Abdominal muscles (rapid breathing, deep breathing, exercise, coughing, sneezing)

Front 54

Focused Health History

Back 54

Respiratory disease, Allergies, cough, Tobacco Exposure, Immunizations, Family, Environment (occupation, housing, travel), Review of systems

Front 55

Thoracic Contour

Back 55

Barrel Chest, Pectus excavatum, Pectus Carinatum, Spinal defomities.

Front 56

Pectus Excavatum

Back 56

The most common congenital deformity of the anterior wall of the chest, in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest. It can either be present at birth or not develop until puberty.

Front 57

Pectus Carinatum (Pigeon chest)

Back 57

A deformity of the chest characterized by a protrusion of the sternum and ribs.

Front 58

Resonance

Back 58

Normal percussion note over adult lung fields is resonance-loud, low, long hallow note.

Front 59

Hyperresonance

Back 59

Overinflated air filled, louder, lower, longer not (children)

Front 60

Diaphragmatic excursion

Back 60

The movement of the thoracic diaphragm during breathing. Normal diaphragmatic excursion should be 3-5 cm, but can be increased in well-conditioned persons to 7-8 cm. This measures the contraction of the diaphragm. It is performed by asking the patient to exhale and hold it. The provider then percusses down their back in the intercostal margins (bone will be dull) starting below the scapula, until sounds change from resonanat to dull (lungs are resonant, solid organs should be dull). That is where the provider marks the spot. Then the patient takes a deep breath in and holds it a s the provider percusses down again, marking the spot where the sound changes from resonant to dull again. The the provider will measure the distance between the two spots. Repeat on the other side, is usually higher up on the right side. If it is less than 3-5 cm, the patient may have a pneumonia or a pneumothorx in which a chest x-ray is diagnostic for either.

Front 61

Normal Breath Sounds

Back 61

Vesicular- soft, airy breezy in periphery

Bronchovesicular- blowing quality over right and left 2nd. ICS @ main stem bronchi

Bronchial- harsh, coarse sound over trachea

Front 62

Crackles/rales

Back 62

Discrete, non-continuous, short (fine, medium, coarse)

Front 63

Rhonchi

Back 63

Continuous, musical quality, usually clears with cough.

Snorous- low pitch

Front 64

Wheezes

Back 64

Sibilant (high pitch)

Front 65

Stridor

Back 65

Harsh, continuous, honking

Front 66

Friction Rub

Back 66

High-pitch grating, squeak

Front 67

Bronchophony

Back 67

Increase loudness/c;aroty of vocal sounds

Front 68

Egophony

Back 68

Normally muffled "eee", abnormal hear "eee" to "ay"

Front 69

Whispered Pectoriliquy

Back 69

Normal barely audible non-distinct word to clear distinct word.

Front 70

Asthma

Back 70

Reactive airway disease

Front 71

Bronchitis

Back 71

Excessive mucus production

Front 72

Emphysema

Back 72

Enlarged alveoli

Front 73

Pleural Effusion

Back 73

Fluid in pleural space

Front 74

Pneumonia

Back 74

Infection

Front 75

Pneumothorax

Back 75

Collapse of lung

Front 76

Kussmaul Breathing

Back 76

Particularly diabetic Ketoacidosis