Nurs 307 Skin Assessment

Front 1

Identify the 9 functions of the integumentary system.

Back 1

Protection
Barrier
Temperature regulation
Wound repair
Absorption/excretion
Production of vitamin D
Perception/sensation
Identification
Communication

Front 2

epidermis layer

Back 2

outer most layer, thin but tough, replaced every 4 weeks

Front 3

subcutaneous layer

Back 3

adipose (fat) tissue

Front 4

dermis layer

Back 4

inner supportive layer, consist of connective tissue (collagen), nerves, sensory receptors, blood vessels, lymphatics, hair follicles, sebaceous glands, and sweat glands

Front 5

If patient is reporting of pain in lesion on skin, what does this tell you about the skin layer it is in?

Back 5

It must be in the dermis because that is where nerve endings are.

Front 6

Identify the 4 appendages to the skin in the integumentary system.

Back 6

Hair
Sebaceous glands - produce sebum
Sweat glands
Nails - hard, keratin plates

Front 7

Identify the 2 types of hair.

Back 7

Vellum - fine hair all over the body
Terminal - scalp, eyebrows

Front 8

Identify the 2 types of sweat glands.

Back 8

Eccrine glands - produce sweat (diluted saline solution) active at 2 months of age

Apocrine glands - produce thick milky secretions, activated in puberty

Front 9

primary lesion

Back 9

first lesion that appears

Front 10

secondary lesion

Back 10

lesion that occurs due to changes over time or changes because of a factor such as scratching or infection

Front 11

macule

Back 11

color change, flat, <1cm (freckle)

Front 12

patch

Back 12

flat, macule that is >1cm (Mongolian spot, café au lait, birthmark)

Note: Same as macule, just large

Front 13

papule

Back 13

elevated, solid lesion <1cm, lesion you can feel (mole, wart)

Front 14

plaque

Back 14

papule >1cm in width (psoriasis)

Tip: Basically a large papule

Front 15

nodule

Back 15

solid, elevated, hard or soft >1cm, extends deeper into dermis

Front 16

tumor

Back 16

>2cm, firm or soft mass (lipoma, hemangioma)

Front 17

wheal

Back 17

superficial, raised lesion (PPD, insect bite)

Front 18

urticaria

Back 18

multiple wheal like lesions, very itchy (hives)

Front 19

vesicle

Back 19

fluid filled, elevated lesion, <1cm (herpes, chicken pox, small blister)

Front 20

bulla

Back 20

>1cm vesicle, (burn, large blister, bullous impetigo)

Front 21

cyst

Back 21

fluid filled cavity extending to dermis or subcutaneous layer (sebaceous cyst)

Front 22

pustule

Back 22

pus filled lesion (acne, pimple); any size

Front 23

crust

Back 23

thickened, dried out exudate left when vesicles/pustules burst or dry up (impetigo)

Front 24

scale

Back 24

flakes of skin, silvery or white (psoriasis, eczema, seborrhea, dermatitis)

Front 25

fissure

Back 25

linear crack with abrupt edges (athletes foot, cracks in
corners of mouth)

Front 26

erosion

Back 26

shallow depression, usually no scar (superficial abrasion)

Front 27

ulcer

Back 27

deep depression, leaves scar usually (decubitus ulcer, bed sore)

Front 28

excoriation

Back 28

self inflicted abrasion, superficial crusting secondary

Front 29

scar

Back 29

healed lesion, replaced with collagen/connective tissue

Front 30

atrophic scar

Back 30

skin level depressed with loss of tissue, thinning (striae/stretch marks)

Front 31

lichenification

Back 31

prolonged intense scratching eventually thickens the skin; common in people with eczema; found in elbows, behind knees

Front 32

keloid

Back 32

elevated scar, feels rubbery; common in darker pigmented people

Front 33

vascular lesion

Back 33

lesions vascular in nature

Tip: Since vascular, there will mostly be a color change

Front 34

spider angioma

Back 34

red, star shaped with solid circular center

Front 35

purpura

Back 35

red/purple patch, flat macular hemorrhage >1cm

Front 36

petechiae

Back 36

tiny, pinpoint, hemorrhage <1-2mm, “little flat blood spots ranging in color - red, purple, or brown

Front 37

ecchymosis

Back 37

flat macular lesion of various colors depending on stage of bruise

Front 38

hemiangioma

Back 38

reddish/blue, solid, spongy collection of benign blood vessels; typically benign

Front 39

Identify the 4 color variations of the skin.

Back 39

Pallor - pale, white
Erythema - redness
Cyanosis - bluish
Jaundice - yellow color

Front 40

Identify and define the pictured condition.

Back 40

Tinea corporis - "ringworm of the body"; skin infection due to fungi

Front 41

Identify and define the pictured condition.

Back 41

psoriasis - scaly, erythematous patch with silvery scales on top

Front 42

Identify and define the pictured condition.

Back 42

Tinea pedis - "athlete's foot', fungal infection that first appears as small vesicle and then grows scaly and hard

Front 43

Identify and define the pictured condition.

Back 43

Herpes zoster (shingles) - small, grouped vesicle that emerge along route of cutaneous sensory nerve; pustules then crusts

Front 44

Identify and define the pictured condition.

Back 44

Tinea capitis - fungal infection of the scalp, "ringworm of the scalp"

Front 45

Identify and define the pictured condition.

Back 45

impetigo - bacterial infection of the skin; moist, thin-roofed vesicle with red base; forms honey-colored crusts; common in infants/kids; caused by streptococcus (strep) or staphylococcus (staph) bacteria

Front 46

Identify and define the pictured condition.

Back 46

diaper/contact dermatitis - inflammatory disease caused by skin irritation from heat, moisture, and diapers

red, moist, maculopapular patch with no defined borders along inguinal and gluteal folds

Front 47

Identify and define the pictured condition.

Back 47

candidiasis - Candida skin infection affecting superficial skin layers

Scalding red, moist patches with marked borders with some loose scales

Front 48

Identify and define the pictured condition.

Back 48

varicella (chicken pox) - infectious disease, esp. of children, causing a mild fever and a rash of itchy inflamed blisters

Front 49

Identify and define the pictured condition.

Back 49

eczema - long-term (chronic) skin disorder that involves scaly and itchy rashes; red papules and vesicle with weeping, oozing, crusting

Front 50

Identify and define the pictured condition.

Back 50

allergic drug reaction - caused by an allergic reaction to a drug; erythematous and symmetric rash, typically generalized

Front 51

Identify and define the pictured condition.

Back 51

tinea versicolor - long-term (chronic) fungal infection of the skin caused by a fungus found normally on skin; patches of pink/tan/white with scaling

Front 52

Identify and define the pictured condition.

Back 52

melanoma - most dangerous type of skin cancer caused by changes in cells called melanocytes; common in individuals with excess UV exposure

Front 53

Identify and define the pictured condition.

Back 53

Kaposi's sarcoma - (patch stage) vascular tumor; most common in HIV-infected persons; AIDS-defining illness; easily mistaken for bruises or nevi and ignored

Front 54

Identify and define the pictured condition.

Back 54

seborrheic dermatitis - "cradle cap"; common, inflammatory skin condition that causes flaky, white to yellowish scales to form on oily areas such as the scalp or inside the ear; occurs with or without reddened skin

Front 55

Identify and define the pictured condition.

Back 55

alopecia areata - sudden apperance of sharply, circumscribed round/oval hairless patch; unknown cause

Front 56

Identify and define the pictured condition.

Back 56

hirsutism - excessive body hair in females forming a sexual pattern (upper lip, chest, arms, legs); caused by endocrine/metabolic dysfunction

Front 57

Identify the medical term for a bruise.

Back 57

ecchymosis

Front 58

Identify the medical classification for a freckle.

Back 58

macule

Front 59

Identify the medical classification for acne.

Back 59

pustule

Front 60

Identify the medical classification for a mole or wart.

Back 60

papule

Front 61

Identify the medical classification for a Mongolian spot.

Back 61

patch

Front 62

Identify the medical classification for a stretch marks.

Back 62

striae (atrophic scarring)

Front 63

Identify the medical classification for a birthmark.

Back 63

patch

Front 64

Identify what needs to documented about each lesion found during the physical assessment. (8)

Back 64

Location
Color
Size
Symmetry
Pattern
Elevation
Odor
Drainage or discharge

Front 65

Identify the 10 aspects of the objective data/physical exam portion a skin assessment.

Back 65

1. Color/General Pigmentation
2. Lesions
3. Temperature
4. Moisture/Dryness
5. Texture
6. Edema
7. Skin Mobility/Skin Turgor
8. Vascular Lesions/Bruising
9. Inspect and Palpate Hair
10. Inspect and Palpate Nails

Front 66

Identify what needs to documented about hair found during the physical assessment. (4)

Back 66

Color
Texture
Distribution
Scalp lesions

Front 67

Identify what needs to documented about nails found during the physical assessment. (5)

Back 67

Shape
Contour (angle 160')
Consistency/texture
Color
Check capillary refill

Front 68

___________ have mild body odor compared to Caucasians and African Americans. (2)

Back 68

Asians and Native Americans

Front 69

In regards to hair, African American tend to be more _______; Asians have _______.

Back 69

In regards to hair, African American tend to be more _______; Asians have _______.

course and dry; silky and straight

Front 70

Identify the ABC's of melanoma,

Back 70

• Asymmetry – cut in half, should be same
• Border – well-defined, regular borders
• Color – uniform color throughout
• Diameter - <5mm is normal; >5mm is abnormal
• Elevation/Changes – raised, growing,