121 Protective Assessment

6 functions of the skin

Protection, body, temperature, regulation, sensation, excretion, maintenance of water, and electrolyte, balance, vitamin D production and absorption

Protective system

The skin is the primary protective system of the body, Primary defense against pathogens, prevents loss of internal fluids, aids, and temperature regulation sensory perception

What is fascia?

A thin layer of connective tissue covering muscles. Muscle contractible fibers that control position and movement of the body highly vulnerable to ischemic damage due to active metabolism that occur in the muscle. Fascia and muscle do not regenerate the heel by scar formation

Cutaneous horn

Larger and harder skin may appear as yellow raised papules

Seborrheic Keratosis

Benign, slightly raised, well circumscribed, tan to black lessons

Striae

Stretch marks from weight gain, pregnancy, obesity

Cutaneous tag

Skin tags and elderly cut benign, raised areas usually the eye area

Hypertrophic scars

From surgery or injuries

Linear Lesion

Straight

Annular lesion

Round rings

Confluent lesion

Lesions run together (ex: chicken pox)

Petechiae

Bleeding or embroil to the skin

Ecchymosis

Bruising with color variation

Hematoma

Localized collection of blood causing elevated bruised area due to trauma

Cherry angioma

Abre related, benign red/purple papeles found on the trunk and extremities

Spider angioma

Due to liver disease, vitamin D deficiency, pregnancy - red lesion with central body and branches

Telangiectasis (varicose veins)

Dilated superficial blood vessels found on the legs and chest, do not blanch

Pustule

Vesicle filled with pus

Nodule

Elevated, solid mass, Extends deeper than the dermis layer of the skin

Cyst

Capitated fluid filled or semi solid mass and dermis or subcutaneous tissue

Assessing lesions: size

Length, width, Diameter, depth, undermining, tunnels

Assessing lesions: appearance

Edges, wound bed, surrounding skin

Assessing lesions: drainage

Amount, color, consistency, odor

Skin issues with the elderly are the result of

Diminished blood flow, and reduced rate of epidermal regeneration, less subcutaneous tissue, less active, sebaceous glands, loss of dermal and epidermal cohesion, reduced Immunologic, action, excessive bathing

Patients susceptible to protective system problems

The clients, diabetes mellitus, Steroids, kidney or liver failure, NSAIDs

Erosion

loss of superficial epidermis, depressed & moist

Ulcer

skin loss past the epidermis, bleeding & scarring – may become necrotic (dead)

Fissure

Linear crack

Scales

flaky dead epithelium, silvery or white, dandruff, psoriasis

Papule

elevated, circumscribed harder mass.

Vesicle

blister formations – such as with herpes zoster.

Wheal

individual elevated lesions, irregularly shaped, varying in color & size – caused by serous fluid in the dermis.