Health Assessment Exam 3

Weeks 3-4

500 mL

How much water is lost from the skin each day in things like sweat, etc?

epidermis

Which layer of the skin is different for everyone?

cholesterol

What substance is converted to Vitamin D on the surface of the skin when reacting with UV radiation?

dermis

supportive layer of the skin

serves as a barrier for bacteria to enter

Why does the skin prevent penetration?

the nerves stemming from the subcutaneous tissue

How does the skin provide perception?

yes

is the skin waterproof?

skin

What is the largest organ?

prevents the loss of fluids and electrolytes

How does the skin balance fluids?

touch, pain, pressure, and temperature

Which of the senses can the skin detect?

sweat through sweat glands and releasing heat from storage in the subcutaneous insulation

How does the skin regulate temperature?

scars, freckles, melanin, fingerprints

How can skin help identify us?

emotion can be expressed in body language through facial expressions, blushing, and blanching

How can the skin help communicate?

wound repair

How does skin replacing itself benefit you?

metabolic wastes, electrolytes, minerals, sugars, amino acids, cholesterol, uric acid, urea

What does the body excrete out of the skin?

Mongolian spots

dark spots (blue, black, or purple) on an infant after birth that normally fade

• caused by melanin being trapped deeper in the skin

• more common in Black, Asian, Latino, and Native American babies

Cafe au lait spots

round or oval patch of light brown pigmentation usually present at birth

acrocyanosis

blueish color around the lips, hands, fingernails, feet and toenails in newborns due to immature circulation

• usually resolves in a few days

mottling

lacey look on infants

• due to dilated blood vessels and immature circulation

jaundice

yellowish tone when baby is born with immature liver

• occurs because body can’t remove bilirubin quick enough

• may occur within 3-4 days of life

light

What breaks down bilirubin?

palms, sclera, bottom of feet

Where can jaundice be seen on patients with darker skin?

lanugo

fine hair covering the skin of an infant

• more may be seen in a premature infant

• dark skinned newborns may have more

milia

“baby acne” on face

• resolve on own within a few months

• small white papules

• caused by keratin being trapped under the skin

vernix caseosa

thick white substance on baby when born

• helps thermoregulate

• higher quantity in premature

• made up of sebum and epithelium cells

striae

“stretch marks”

• silver to pink color

• appear in second trimester

linea negra

brown/black line down the midline of the stomach during pregnancy

chloasma

discoloration or hyperpigmentation of skin when pregnant

• most are seen on the face and look like freckles

• disappears after delivery

vascular spiders

occur due to extra blood volume and estrogen during pregnancy

• appear with tiny red centers with radiating branches

solar lentigines

also known as “liver spots” or “sun spots”

• flat brown spots caused by sun exposure

• seen most prominently on face and hands

xerosis

dry skin

• due to decrease in sweat and sebaceous glands

acrochordons

“skin tags”

• overgrowths of normal skin

• commonly found on eyelids, cheeks, and neck

decreased melanocytes

Why does hair turn gray with age?

social isolation, infection, ineffective thermoregulation, injury

threats of poor skin integrity in older adults

ineffective coping and infection

threats of poor skin integrity in adolescents

ineffective thermoregulation and absorption rates differ

developmental consequences of poor skin integrity in infants

sepsis, impaired body image, and pain

What can poor skin integrity cause?

masses

What are you testing the mobility of in skin assessment?

turgor

tested by pinching the skin and seeing how fast it returns

• tenting

vascular

What kind of problem is present when a patient has a white patch of hair?

divide hair into sections and inspect

How do you assess head for lesions?

pediculus

“head lice”

• parasitic insects that feed on blood

• only live 12 hours off the head

they can’t stick to products and heat kills them

Why is lice not as common in adults?

clubbing

nailbed is greater than 160 degrees, looks flat with no concave

congenital cyanotic heart disease, lung cancer, and pulmonary diseases

What can clubbing be a sign of?

color return in less than 3 seconds

What is normal for capillary refill?

erythema, jaundice, pallor, cyanotic

What words are used for an abnormal skin assessment relating to color?

hypothermia and hyperthermia

What words are used for abnormal skin assessment relating to temperature?

diaphoresis and dehydration

What words are used for abnormal skin assessment relating to moisture?

diaphoresis

excess sweating

smooth or rough

What words are used for skin texture in an assessment?

pitting or non pitting

What words are used to describe edema in a skin assessment?

grade +1 edema

pits < 2mm, disappears immediately

grade +2 edema

pits 2-4mm, mild edema, 10-15 seconds to disappear

grade +3 edema

4-6 mm deep, moderate edema, disappears in less than 2 minutes

grade +4 edema

6-8 mm deep, severe edema, disappears in 2-5 minutes

macule

type of lesion that is flat, 1mm or less, and is only a change in color

papule

type of lesion that is raised

• is a thickening at the dermis

• ex. mole

nodule

type of lesion that is solid and elevated

• extends deeper into the dermis

• can be hard or soft

• greater than 1 cm

tumor

type of lesion that is larger than a nodule, can be firm or soft, elevated

• goes deeper into the dermis

• can be benign or malignant

vesicle

type of lesion, known as a blister

• elevated cavity containing free fluid

• up to 1 cm

bulla

larger blister

pustule

type of lesion that is elevated and contains pus

• goes into dermis

wheal

superficial raised type of lesion

• due to edema, hives, or a bee sting

• appears to be a raised rash

cyst

type of lesion that goes into dermis

• encapsulated clear and cloudy fluid

pallor

could be caused by:

• high stress(anxiety or fear)

• exposure to cold

• cigarette smoking

• edema

• anemia

• shock

• arterial deficency

erythema

could be caused by:

• fever

• blushing

• inflammation

• carbon monoxide poisoning

cyanosis

could be caused by:

• shock

• cardiac arrest

• heart failure

• chronic bronchitis

• congenital heart disease

indicates hypoxemia

jaundice

could be caused by:

• liver disease

• hepatitis

• cirrhosis(advanced scarring of the liver)

• sickle cell

• transfusion reaction

ABCDEF

What is the assessment tool for melanoma detection?

asymmetry

What does the A stand for in the ABCDEF tool?

border

What does the B stand for in the ABCDEF tool?

jagged edges, scalloping, poorly defined margins

What is abnormal for the border of a mole?

color

What does the C stand for in the ABCDEF tool?

higher melanoma risk

What does it mean if a mole is more than one color?

diameter

What does the D mean in the ABCDEF tool?

greater than 6 mm or the size of a pencil eraser

What is alarming for diameter of a mole?

Evolution

What does the E stand for in the ABCDEF tool?

funny looking

What does F mean in the ABCDEF tool?

nevi

another name for skin mark or mole

risk for pressure sores

What does the Braden scale examine?

higher risk for pressure sores

What does a lower score on the Braden scale mean?

risk factors for the braden scale

• sensory perception

• moisture

• activity

• mobility

• nutrition

• friction and shear

<9

severe risk on the braden scale

10-12

high risk on braden scale

13-14

moderate risk on braden scale

15-18

mild risk on braden scale

no

can pressure injuries go backward in stages?

stage 1 pressure injury

non blanchable erythema

• no open wound

stage 2 pressure injury

partial thickness skin loss

• shallow break in the skin, pink/red

stage 3 pressure injury

full thickness skin loss

• goes into subcutaneous

• no muscle, bone, or tendon

stage 4 pressure injury

full thicken skin and tissue loss

• down to bone, muscle, or tendon

• may have tunneling or undermining

deep tissue pressure injury

no break in skin, looks like a bruise or black spot

unstageable pressure injury

pressure injury where you cannot tell how deep until eschar is removed

• hard to distinguish what is what

eschar

dead tissue appearing black in or covering pressure injuries

slough

stringy matter attached to wound bed

• appears yellow or white

deep tissue injury

What pressure injury does this depict?

stage 1 pressure injury

What pressure sore does this depict?

stage 2 pressure injury

What pressure sore does this depict?

stage 3

What pressure sore does this depict?