skin - HealthAssess 3.0

Skin color is a combination of ____, ____, and the underlying ____ bed.

Skin color is a combination of melanin, carotene, and the underlying vascular bed.

Areas of increased blood flow such as the ___ , ___, and _____ often have reddened tones.

Areas of increased blood flow such as the cheeks, chest, and genitals often have reddened tones.

Skin color variations can be generalized or localized, with areas exposed to the ____ often having increased pigmentation.

Skin color variations can be generalized or localized, with areas exposed to the sun often having increased pigmentation.

__ occurs when melanin is increased in one area, leading to darker skin patches.

Hyperpigmentation

Common examples of hyperpigmentation include ______, __ ______, and ______ changes.

birthmarks, sun damage, pregnancy changes

Freckles are an example of __.

hyperpigmentation

__ occurs when melanin is decreased in one area, but not completely absent.

Hypopigmentation

Examples of hypopigmentation include ___, _____ ____, and ______.

scars, stretch marks, and vitiligo.

__ is the total lack of brown melanin pigment in patchy areas of the skin.

Vitiligo

______ is caused by a lack of oxygen to the tissues and appears as a bluish skin color.

Cyanosis

In darker skin tones, cyanosis presents as ____ skin with ___ undertones, observed in the ___ ____ and ___ beds.

In darker skin tones, cyanosis presents as darker skin with dull undertones, observed in the oral mucosa and nail beds.

_____ results from bleeding under the skin and appears as blotches or larger spots.

Ecchymosis

In lighter skin, ecchymosis changes to ____ or ____ as it heals, while in darker skin, _____ may be more difficult to see.

In lighter skin, ecchymosis changes to blue or yellow as it heals, while in darker skin, bruises may be more difficult to see.

__ are small purple or red spots indicating bleeding under the skin.

Petechiae

________ is caused by inflammation and presents as flushed skin.

Erythema

____ is a yellowish skin color caused by increasing levels of _____.

Jaundice is a yellowish skin color caused by increasing levels of bilirubin.

In lighter skin, jaundice is most noticeable on the ____ and ___ ____.

In lighter skin, jaundice is most noticeable on the sclera and hard palate.

__ is a pale or lighter skin color, indicating anemia or circulatory issues.

Pallor

In lighter skin, pallor appears white, while in darker skin it appears as __ or dull grey.

yellow-brown

The expected findings when assessing skin texture and moisture should be ______ and uniformly ___.

The expected findings when assessing skin texture and moisture should be smooth and uniformly dry.

____ is a skin condition characterized by blackheads, whiteheads, pimples, oily skin, and possible scarring.

Acne

As skin ages, the epidermis __ , __production decreases, skin ___ diminishes, and __ increases.

As skin ages, the epidermis thins , oils production decreases, skin elasticity diminishes, and wrinkling increases.

____ are fibrous tissue that forms during healing of skin lesions or injuries.

Scars

Extremely smooth and soft skin, feeling like velvet, could signal ___ ____.

thyroid disease.

Rough, dry, and flaky skin could be a sign of ___ or ___.

Rough, dry, and flaky skin could be a sign of thyroid disease or dehydration.

__ is excessive perspiration caused by an increased metabolic rate due to fever, thyroid disorders, or increased activity.

Diaphoresis

Excessive perspiration with skin pallor could indicate __.

heart failure

A skin ____ is a change in the integrity of the skin, which can be caused by trauma, infection, or disease.

lesion

The key characteristics to document when assessing a skin lesion include ____, ____, ___, ___, ____, and presence of ____.

The key characteristics to document when assessing a skin lesion include color, height, shape, size, location, and presence of drainage.

______ ____ result from blood leaking from blood vessels into the dermis.

Vascular lesions

____ are small (1-3 mm) reddish-purple spots caused by trauma or infection.

Petechiae

_____ is a collection of blood in the dermis greater than 3 mm, initially reddish-purple.

Ecchymosis

_____ is a collection of petechiae and ecchymosis covering a larger area.

Purpura

____ ____ ___ include macules and patches.

Flat primary lesions

_____ ____ ____ include papules, plaques, and wheals.

Raised primary lesions

Raised, solid primary lesions include ____ and __.

Raised, solid primary lesions include nodules and tumors.

Raised, ___-____ primary lesions include vesicles, bullae, pustules, and cysts.

fluid-filled

____ ___ evolve from primary lesions over time, such as lichenification and crust.

Secondary lesions

_______ are straight-line cracks with abrupt edges that extend into the dermis.

Fissures

Potentially malignant lesions may indicate ____ ____.

skin cancer

The ABCDE rule helps evaluate skin lesions: _______, _____ irregularity, ____ variation, _____ greater than __ mm, and ____.

Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Evolving.

The "____ _____" sign refers to identifying a mole that looks or behaves differently from the surrounding nevi.

ugly duckling

Pressure injuries should be assessed frequently, typically every __ in clients with limited mobility.

4 hours

Stage I is characterized by a reddened area that does not __ with pressure.

blanch

Stage __ involves partial loss of the dermis, often presenting as a shiny or dry ulcer with a pink wound bed.

Stage 2

Stage ___ is marked by full-thickness skin loss with damage or necrosis of subcutaneous tissue.

stage 3

Stage ___ pressure injuries involve full-thickness skin loss with exposure of bones, tendons, or muscles.

stage 4

To measure a pressure injury, measure the _____ dimension of the wound and then measure the perpendicular dimension.

largest

Signs of infection include increased _____, tissue _____, ____, ___, and increased ___.

Signs of infection include increased redness, tissue necrosis, fever, chills, and increased pain.

The client's skin should be warm and consistent across all body parts, indicating a well-functioning __ system.

circulatory

If the environment is cold, the hands and feet may be naturally cooler than the __.

torso

Hyperthermia could indicate a __, often in response to an infection.

fever

Hypothermia refers to a generalized cool body temperature, often due to poor __, such as in cardiac arrest or shock.

perfusion

In older clients, the skin may show delayed return to its original position due to decreased __.

elasticity

_____ can indicate significant weight loss or severe dehydration.

Tenting

Edema is the accumulation of excess fluid in the __ spaces between tissues.

interstitial

Edema often collects in dependent areas, such as the ___, ___, and __ areas.

Edema often collects in dependent areas, such as the feet, ankles, and sacral areas.

____ ____ occurs when pressure on the affected area leaves an indentation.

Pitting edema

A ____-___ scale is used to document the severity of pitting edema.

four-point

Nails should be slightly curved or flat, with _____ edges at the cuticles.

smooth

Capillary refill should return in __ seconds.

less than 2

Older adults often experience slower ____ growth, ____ nails, and nails that may be more difficult to ___.

Older adults often experience slower nail growth, thicker nails, and nails that may be more difficult to trim.

Brown streaks may appear in clients with darker skin tones due to increased __.

pigmentation

A bluish tinge indicates __, which is a sign of low oxygen levels in the bloodstream.

cyanosis

Whitish nails can be a sign of __.

anemia

_____ nails feel spongy at the base and have a downward curve.

clubbed

_____ nails may result from nail-biting habits or brittle nails.

Jagged

____ and ____ nails may be caused by poor blood flow in the arteries.

Thickened and rigid nails may be caused by poor blood flow in the arteries.

Pitted nails may be a sign of a nutritional deficiency, acute illness, or certain conditions like psoriasis.

Pitted nails

_____ grooves or _____ across the nails could be caused by severe illness, trauma, or cold exposure.

Transverse grooves or lines across the nails could be caused by severe illness, trauma, or cold exposure.

Delayed capillary refill could indicate a problem with ____ ___ ____ or _____ issues.

Delayed capillary refill could indicate a problem with peripheral blood vessels or respiratory issues.

The goal of ______ in skin care is to remove accumulated oil, sweat, dead skin cells, and harmful bacteria.

bathing

The ideal bath water temperature for skin care is between __ degrees Celsius.

43°C = 109.4°F

46°C = 114.8°F

Alcohol-free and perfume-free products are recommended for __ skin to reduce irritation.

sensitive

Keep the abrasion ____ and ___ to manage an abrasion.

Keep the abrasion clean and dry to manage an abrasion.

Use ____-___ lotions to moisturize skin, ___ less frequently, or avoid ___ to manage excessive skin dryness.

Use alcohol-free lotions to moisturize skin, bathe less frequently, or avoid soap to manage excessive skin dryness.

To prevent infection and scarring, never squeeze or pick at __ lesions.

acne

Apply a broad-spectrum sunscreen with SPF __ or greater 15 minutes before sun exposure.

30

Indoor tanning increases the risk of skin _____.

cancer

Risk factors for developing skin cancer include significant ___ exposure and a family history of ____.

Risk factors for developing skin cancer include significant UV exposure and a family history of melanoma.

Clients should examine their skin regularly in a well-lit room with a __.

mirror

Early identification and treatment of suspicious lesions increase the chances of __ outcomes.

better

All clients should use _____ to prevent sun damage, premature aging, and skin cancer.

sunscreen