Integumentary Screening

Where are some common pressure sore areas?

bony prominences: back of head, shoulder, elbow, hip, heel

Stage 1 pressure ulcer

skin is still intact

Stage 2 pressure ulcer

dermis is exposed, partial thickness skin loss

Stage 3 pressure ulcer

fat/adipose tissue visible, slough /eschar present

Stage 4 pressure ulcer

bone is exposed

True or false: pitting edema only occurs with serious health conditions

false: mild pitting edema can occur with acute injuries such as ankle sprains

What does bilateral pitting edema indicate?

heart conditions such as congestive heart failure

What does unilateral pitting edema indicate?

venous obstruction or lymphatic blockage

Pitting edema scale: 0

no pitting edema

Pitting edema scale: 1+

mild pitting edema, 2mm depression that disappears rapidly

Pitting edema scale: 2 +

moderate pitting edema, 4mm depression that disappears in 10-15 seconds

Pitting edema scale: 3+

moderate severe pitting edema, 6mm depression that lasts >1 min

Pitting edema scale: 4+

severe pitting edema, 8mm depression that lasts >2 min

What is hemosiderin staining?

rusty brown darkening of skin due to venous valve failure

Where is hemosiderin staining most common?

distal lower extremities

What is lipodermatosclerosis?

inflammation of subcutenous fat, skin hardening

What is an indication of peripheral artery disease?

dependent rubor: limb appears red on feet/lower legs in a dependent position

What are some signs of cellulitis?

hot, acutely painful, edema, induration, spreading redness

What is a reactive erythema?

acute onset rash from non-infectious causes such as bug bite,mild allergic reactions

What is precancerous growths called?

actinic keratoses

How is melanoma different from other skin cancer types?

malignant form of skin cancer, specifically out of control melanocyte growthT

True or false: melanoma has a low survival rate

false: melanoma has one of the higher survival rates in the early stages

What are some risk factors for Melanoma?

UV exposure, repeated sunburns, weak immune system, family hx

Which of the following is NOT a normal characteristic of a mole

> ¼ diameter

How is nodular melanoma different from regular melanoma?

most aggressive form, typically occurs in men >60 and occurs in any part of the body

Why do we assess nail beds?

can indicate several other disorders

What is koilonychia indicate?

anemia, thyroid disorder, syphilis

What does Beau’s lines indicate?

alcohol abuse, nutrition, MI

What does nail pitting indicate?

psorasis

What does Onycholysis indicate?

fungus/psorasisW

What does a dark brown line on the nail indicate?

melanoma, malignant cancerW

What is a mongolian spot?

Congenital birthmarks found on babies that typically fade but can stay