skin - HealthAssess 3.0

Flashcard 1: Skin Color Variations

• Question: What factors contribute to skin color?

• Answer: Skin color is a combination of melanin (brown pigments), carotene (yellow pigments), and the underlying vascular bed (red), creating a range of colors from whitish pink to dark brown with yellow or olive tones.

Flashcard 2: Normal Skin Color Findings

• Question: What should the skin color of a client look like?

• Answer: The skin color should be even and consistent with the client's genetic background.

Flashcard 3: Areas of Increased Reddened Tones

• Question: Which areas of the body often have increased reddened tones?

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

Flashcard 4: Variations in Skin Color

• Question: What are expected skin color variations?

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

Flashcard 5: Hyperpigmentation Definition

• Question: What is hyperpigmentation?

• Answer: Hyperpigmentation occurs when melanin is increased in one area, leading to darker skin patches.

Flashcard 6: Examples of Hyperpigmentation

• Question: What are common examples of hyperpigmentation?

• Answer: Examples include birthmarks, sun damage, and pregnancy changes such as melasma (chloasma) and solar lentigines (age spots).

Flashcard 7: Freckles as Hyperpigmentation

• Question: Are freckles considered hyperpigmentation?

• Answer: Yes, freckles are an example of hyperpigmentation.

Flashcard 8: Hypopigmentation Definition

• Question: What is hypopigmentation?

• Answer: Hypopigmentation occurs when melanin is decreased in one area, but not completely absent.

Flashcard 9: Examples of Hypopigmentation

• Question: What are some examples of hypopigmentation?

• Answer: Examples include scars, stretch marks, and vitiligo.

Flashcard 10: Vitiligo

• Question: What is vitiligo?

• Answer: Vitiligo is the total lack of brown melanin pigment in patchy areas of the skin, commonly affecting clients with darker skin tones.

Flashcard 1: Cyanosis Definition

• Question: What is cyanosis?

• Answer: Cyanosis is caused by a lack of oxygen to the tissues and appears as a bluish skin color in lighter skin tones.

Flashcard 2: Cyanosis in Darker Skin

• Question: How can cyanosis be detected in darker skin tones?

• Answer: In darker skin tones, cyanosis presents as darker skin with dull undertones. It can be observed in the oral mucosa and nail beds.

Flashcard 3: Ecchymosis Definition

• Question: What is ecchymosis?

• Answer: Ecchymosis, or bruising, results from bleeding under the skin and appears as blotches or larger spots that change color as they heal.

Flashcard 4: Ecchymosis in Lighter vs Darker Skin

• Question: How does ecchymosis appear in lighter vs darker skin tones?

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

Flashcard 5: Petechiae

• Question: What is petechiae?

• Answer: Petechiae are small purple or red spots indicating bleeding under the skin due to tiny hemorrhages in the dermal layer.

Flashcard 6: Erythema Definition

• Question: What is erythema?

• Answer: Erythema is caused by inflammation and presents as flushed skin, which appears as an intense red color in lighter skin tones or a purplish tinge in darker skin tones.

Flashcard 7: Jaundice Definition

• Question: What is jaundice?

• Answer: Jaundice is a yellowish skin color caused by increasing levels of bilirubin, a by-product of red blood cell breakdown.

Flashcard 8: Jaundice in Lighter and Darker Skin

• Question: Where is jaundice most noticeable in lighter and darker skin tones?

• Answer: In lighter skin, jaundice is most noticeable on the sclera (eyes) and hard palate. In darker skin, it may also be noted on the palms and soles.

Flashcard 9: Pallor Definition

• Question: What is pallor?

• Answer: Pallor is a pale or lighter skin color, indicating anemia or circulatory issues.

Flashcard 10: Pallor in Lighter vs Darker Skin

• Question: How does pallor appear in lighter vs darker skin tones?

• Answer: In lighter skin, pallor appears white, while in darker skin, it appears as yellow-brown or dull grey. It is best observed on the lips, mucus membranes, and nail beds.

Flashcard 1: Expected Findings - Skin Texture and Moisture

• Question: What are the expected findings when assessing skin texture and moisture?

• Answer: The skin should be smooth and uniformly dry, with varying amounts of oil, which can range from dry skin (xerosis) to oily skin (seborrhea).

Flashcard 2: Acne Definition

• Question: What is acne and what causes it?

• Answer: Acne is a skin condition characterized by blackheads, whiteheads, pimples, oily skin, and possible scarring. It is often triggered by stress and is common during adolescence due to increased sweat and oil production.

Flashcard 3: Wrinkles and Aging

• Question: How does aging affect skin texture and appearance?

• Answer: As skin ages, the epidermis thins, oil production decreases, skin elasticity diminishes, and wrinkling increases. Skin healing also slows down.

Flashcard 4: Scar Formation

• Question: What are scars, and what types can they be?

• Answer: Scars are fibrous tissue that forms during healing of skin lesions or injuries. Types of scars include atrophic scars (depressions from skin loss) and keloids (overgrowth of scar tissue beyond the original wound).

Flashcard 5: Velvety Skin

• Question: What does velvety skin indicate?

• Answer: Extremely smooth and soft skin, feeling like velvet, could signal thyroid disease.

Flashcard 6: Roughness, Dryness, and Flakiness

• Question: What could rough, dry, and flaky skin indicate?

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

Flashcard 7: Diaphoresis Definition

• Question: What is diaphoresis, and what can cause it?

• Answer: Diaphoresis is excessive perspiration caused by an increased metabolic rate due to fever, thyroid disorders, or increased activity. It can also occur with shock, severe pain, or anxiety.

Flashcard 8: Diaphoresis and Heart Failure

• Question: What could excessive perspiration and skin pallor indicate?

• Answer: Excessive perspiration with skin pallor could indicate heart failure.

Flashcard 1: Skin Lesions - General Information

• Question: What is a skin lesion, and why is it important to assess?

• Answer: A skin lesion is a change in the integrity of the skin, which can be caused by trauma, infection, or disease. It is important to assess lesions for changes that are new or have recently altered, as they may indicate underlying health conditions.

Flashcard 2: Characteristics of Skin Lesions

• Question: What are the key characteristics to document when assessing a skin lesion?

• Answer: The following characteristics should be documented:

  • Color

  • Height: flat or raised

  • Shape of the lesion

  • Size: measured in centimeters

  • Location: single area or generalized

  • Presence of drainage: note color and odor

Flashcard 3: Types of Skin Lesions - Vascular Lesions

• Question: What are vascular lesions, and what causes them?

• Answer: Vascular lesions result from blood leaking from blood vessels into the dermis. They can occur due to trauma, infection, or disease. Examples include petechiae, ecchymosis, and purpura.

Flashcard 4: Petechiae

• Question: What are petechiae, and what causes them?

• Answer: Petechiae are small (1-3 mm) reddish-purple spots caused by trauma or infection. They indicate bleeding under the skin.

Flashcard 5: Ecchymosis

• Question: What is ecchymosis, and how does it change over time?

• Answer: Ecchymosis is a collection of blood in the dermis greater than 3 mm, initially reddish-purple, which changes to blue or yellow as it heals. It is typically caused by trauma.

Flashcard 6: Purpura

• Question: What is purpura?

• Answer: Purpura is a collection of petechiae and ecchymosis covering a larger area, often caused by infections or bleeding disorders.

Flashcard 7: Primary Skin Lesions - Flat Lesions

• Question: What are flat primary lesions, and what are some examples?

• Answer: Flat primary lesions include macules (less than 1 cm) and patches (greater than 1 cm). These lesions are typically caused by pigmentation changes and can be seen in conditions like freckles, moles, and vitiligo.

Flashcard 8: Primary Skin Lesions - Raised Lesions

• Question: What are raised primary lesions, and what are some examples?

• Answer: Raised primary lesions include papules (less than 1 cm), plaques (larger than 1 cm), and wheals(irregular areas of edema). Examples include warts, psoriasis, and hives.

Flashcard 9: Raised, Solid Lesions

• Question: What are raised, solid primary lesions, and examples?

• Answer: These lesions include nodules (less than 2 cm, firm, arising from deeper layers) and tumors (larger than 2 cm, firm). They can be associated with conditions like melanoma and lipoma.

Flashcard 10: Raised, Fluid-Filled Lesions

• Question: What are raised, fluid-filled primary lesions, and examples?

• Answer: These lesions include vesicles (less than 1 cm, serous fluid), bullae (greater than 1 cm, serous fluid), pustules (less than 1 cm, purulent fluid), and cysts (encapsulated, filled with liquid/semi-solid). Examples include shingles, blisters, and cystic acne.

Flashcard 11: Secondary Skin Lesions

• Question: What are secondary skin lesions, and how do they develop?

• Answer: Secondary lesions evolve from primary lesions over time. Examples include lichenification (thickened skin from scratching), crust (scabs), scale (excessive shedding of keratin), and fissures (cracks into the dermis).

Flashcard 12: Fissures

• Question: What are fissures in the context of skin lesions?

• Answer: Fissures are straight-line cracks with abrupt edges that extend into the dermis. They are commonly seen in conditions like cracked heels or cheilosis (cracks in the mouth corners).

Flashcard 13: Potentially Malignant Skin Lesions

• Question: What is the importance of assessing potentially malignant skin lesions?

• Answer: Potentially malignant lesions may indicate skin cancer, particularly melanoma. Early detection increases the chances of successful treatment.

Flashcard 14: ABCDE Rule for Skin Cancer Assessment

• Question: What is the ABCDE rule for assessing skin lesions for melanoma?

• Answer: The ABCDE rule helps evaluate skin lesions:

  • A: Asymmetry

  • B: Border irregularity

  • C: Color variation

  • D: Diameter greater than 6 mm

  • E: Evolving (changes in size, symptoms, or composition)

Flashcard 15: "Ugly Duckling" Sign for Skin Cancer

• Question: What is the "ugly duckling" sign in assessing for skin cancer?

• Answer: The "ugly duckling" sign refers to identifying a mole that looks or behaves differently from the surrounding nevi. It may appear itchy, burn, or bleed and should be evaluated for possible malignancy.

Flashcard 1: Pressure Injuries - Definition

• Question: What is a pressure injury, and what causes it?

• Answer: A pressure injury, also known as a pressure ulcer or bedsore, occurs when local circulation is impaired to underlying tissue due to prolonged pressure over bony prominences. This can be caused by factors like immobility, poor nutrition, or moisture.

Flashcard 2: Risk Factors for Pressure Injuries

• Question: What are some common risk factors for pressure injuries?

• Answer:

  • Limited ability to reposition

  • Thinner skin due to aging

  • Poor nutritional state

  • Presence of moisture (incontinence, wound drainage, perspiration)

  • Friction injuries from being pulled across bed linens

Flashcard 3: Assessment of Pressure Injuries

• Question: How often should pressure injuries be assessed in high-risk clients?

• Answer: Pressure injuries should be assessed frequently, typically every 4 hours or according to facility policy, in clients with limited mobility or high risk for pressure ulcers.

Flashcard 4: Staging of Pressure Injuries - Stage I

• Question: What are the characteristics of a Stage I pressure injury?

• Answer: Stage I is characterized by a reddened area that does not blanch with pressure. The texture and temperature are different from surrounding tissue, and it may feel firmer or softer.

Flashcard 5: Staging of Pressure Injuries - Stage II

• Question: What are the characteristics of a Stage II pressure injury?

• Answer: Stage II involves partial loss of the dermis, often presenting as a shiny or dry ulcer with a pink wound bed. It may appear as an intact or ruptured blister.

Flashcard 6: Staging of Pressure Injuries - Stage III

• Question: What are the characteristics of a Stage III pressure injury?

• Answer: Stage III is marked by full-thickness skin loss with damage or necrosis of subcutaneous tissue. Subcutaneous fat may be visible, and dead tissue may be present in the wound bed.

Flashcard 7: Staging of Pressure Injuries - Stage IV

• Question: What are the characteristics of a Stage IV pressure injury?

• Answer: Stage IV pressure injuries involve full-thickness skin loss with exposure of bones, tendons, or muscles. Dead tissue may be present in the wound bed.

Flashcard 8: Measuring Pressure Injuries

• Question: How do you measure a pressure injury?

• Answer: Measure the largest dimension of the wound, then measure the perpendicular dimension. Multiply the two measurements to estimate the affected surface area. Measure the depth using a sterile applicator swab inserted into the deepest part of the wound.

Flashcard 9: Signs of Infection in Pressure Injuries

• Question: What signs should you monitor for to detect infection in pressure injuries?

• Answer: Signs of infection include increased redness, tissue necrosis, fever, chills, and increased pain. Drainage should be noted for color, type, and odor.

Flashcard 10: Interventions to Prevent Pressure Injuries

• Question: What are some key interventions to prevent pressure injuries?

• Answer:

  • Inspect the skin frequently, typically every 4 hours

  • Reposition clients with decreased mobility every 2 hours

  • Elevate the head of the bed no more than 30° to avoid shearing injuries

  • Remove sources of excessive moisture

  • Provide nutritional supplements as needed

  • Never rub a reddened area (Stage I injury)

Flashcard 11: Wound Care for Pressure Injuries

• Question: How should wound care be performed for pressure injuries?

• Answer: Follow facility guidelines for wound care, ensuring proper cleaning, dressing, and prevention of further injury. Never rub a reddened area, as it can worsen the injury.

Flashcard 12: Documentation of Pressure Injuries

• Question: What should be documented when assessing a pressure injury?

• Answer: Document the location, size, depth, appearance, and presence of drainage, including the characteristics of any drainage.

Flashcard 1: Expected Skin Temperature

• Question: What is the expected skin temperature for a client?

• Answer: The client's skin should be warm, similar to the temperature of your hands, and consistent across all body parts, indicating a well-functioning circulatory system.

Flashcard 2: Expected Variations in Skin Temperature

• Question: What factors can cause expected variations in skin temperature?

• Answer:

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

  • Immobilization, such as a cast, or circulation problems in an extremity can also cause slight cooling in that area.

Flashcard 3: Hyperthermia

• Question: What could an elevated body temperature indicate?

• Answer: Hyperthermia, or elevated body temperature, could indicate a fever, often in response to an infection. It can also be due to inflammation in a painful joint, trauma, infection, or sunburn if localized.

Flashcard 4: Hypothermia

• Question: What is hypothermia, and what are its causes?

• Answer: Hypothermia refers to a generalized cool body temperature, often due to poor perfusion, such as in cardiac arrest or shock. Localized coolness, such as in an extremity, could be caused by decreased blood flow, like in cases of blood clots or circulatory diseases.

Flashcard 1: Expected Skin Turgor

• Question: How should the skin react when pinched?

• Answer: The skin should rise easily when pinched and return to the flat position rapidly when released.

Flashcard 2: Expected Variations in Skin Turgor

• Question: What is a common variation in skin turgor for older adults?

• Answer: In older clients, the skin may show delayed return to its original position due to decreased elasticity, which is a natural result of aging and thinning of the dermis.

Flashcard 3: Tenting

• Question: What does it mean if the skin remains elevated after being pinched?

• Answer: This is called tenting, which can indicate significant weight loss or severe dehydration.

Flashcard 4: Edema

• Question: What is edema, and what causes it?

• Answer: Edema is the accumulation of excess fluid in the interstitial spaces between tissues. It can be caused by various factors, such as heart or kidney failure (generalized edema) or infection or trauma (localized edema).

Flashcard 5: Edema and Skin Color

• Question: How can edema affect the appearance of skin color?

• Answer: Edema can stretch the skin, making dark skin appear lighter, which could mask signs of jaundice or cyanosis.

Flashcard 6: Dependent Edema

• Question: Where does edema commonly collect due to gravity?

• Answer: Edema often collects in dependent areas, such as the feet, ankles, and sacral areas (lower back). This can limit mobility and increase the risk of pressure injuries.

Flashcard 7: Pitting Edema

• Question: What is pitting edema, and how is it assessed?

• Answer: Pitting edema occurs when pressure on the affected area leaves an indentation. To assess, apply pressure for 3–4 seconds and observe for an indentation. If the skin remains smooth, it is nonpitting. If an indentation is present, measure the depth of the pit in millimeters.

Flashcard 8: Edema Severity Scale

• Question: How is the severity of pitting edema documented?

• Answer: A four-point scale is used:

  • 1+ (barely detectable indentation)

  • 2+ (slight indentation, returns to normal in 15 seconds)

  • 3+ (deep indentation, returns to normal in 30 seconds)

  • 4+ (very deep indentation, lasts more than 30 seconds)

Flashcard 1: Expected Nail Characteristics

• Question: What are the expected characteristics of healthy nails?

• Answer: Nails should be slightly curved or flat, with smooth, rounded edges at the cuticles. The thickness should be uniform, and the nail is translucent, with a color similar to the client’s skin tone.

Flashcard 2: Capillary Refill Test

• Question: How is capillary refill tested and what is the expected result?

• Answer: Apply pressure to the nail edge for 5 seconds, then release and observe how long it takes for the nailbed to return to its normal color. Capillary refill should return in less than 2 seconds.

Flashcard 3: Expected Variation in Older Adults

• Question: What nail changes are common in older adults?

• Answer: Older adults often experience slower nail growth, thicker nails, and nails that may be more difficult to trim. Their nails can become brittle or peel, and sometimes turn yellow.

Flashcard 4: Brown Streaks in Nails

• Question: What do brown streaks in the nails indicate?

• Answer: Brown streaks may appear in clients with darker skin tones due to increased pigmentation. A single, thin, uniform streak may be a mole underneath the nail, but a wide, growing streak with irregular edges could indicate melanoma.

Flashcard 5: Bluish Tinge in Nails

• Question: What does a bluish tinge in the nails indicate?

• Answer: A bluish tinge indicates cyanosis, which is a sign of low oxygen levels in the bloodstream and could point to circulation or lung problems.

Flashcard 6: Whitish Nails

• Question: What can whitish nails (pallor) indicate?

• Answer: Whitish nails can be a sign of anemia.

Flashcard 7: Clubbed Nails

• Question: What are the characteristics of clubbed nails, and what conditions can they indicate?

• Answer: Clubbed nails feel spongy at the base and have a downward curve. They are associated with congenital heart disease, inflammatory bowel disease, and other pulmonary diseases.

Flashcard 8: Jagged Nails

• Question: What do jagged nails typically indicate?

• Answer: Jagged nails may result from nail-biting habits or brittle nails.

Flashcard 9: Thickened and Rigid Nails

• Question: What can thickened, rigid nails indicate?

• Answer: Thickened and rigid nails may be caused by poor blood flow in the arteries, leading to a lack of flexibility in the nails.

Flashcard 10: Pitted Nails

• Question: What do pitted nails suggest?

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

Flashcard 11: Transverse Grooves in Nails

• Question: What do transverse grooves or lines across the nails indicate?

• Answer: These grooves could be caused by severe illness, trauma, or cold exposure, especially in clients with Raynaud's disease.

Flashcard 12: Delayed Capillary Refill

• Question: What does delayed capillary refill (more than 2 seconds) indicate?

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

Flashcard 1: Goal of Bathing

• Question: What is the goal of bathing in skin care?

• Answer: The goal is to remove accumulated oil, sweat, dead skin cells, and harmful bacteria, while promoting good circulation. Bathing also provides a sense of well-being and nourishment for the skin.

Flashcard 2: Ideal Bath Water Temperature

• Question: What is the ideal bath water temperature for skin care?

• Answer: Comfortable bath water temperature is between 43°C to 46°C (110°F to 115°F).

Flashcard 3: Skin Care Products

• Question: What types of skin care products are recommended for sensitive skin?

• Answer: Alcohol-free and perfume-free products are recommended to reduce skin irritation. Avoid using old makeup or skin care products, especially around the eyes (discard after 4 months).

Flashcard 4: Managing Abrasions

• Question: What should be done to care for an abrasion?

• Answer: Keep the abrasion clean and dry. If covered with a bandage, check for drainage or retained moisture, as these can create a warm, moist environment for infection.

Flashcard 5: Managing Excessive Skin Dryness

• Question: How can excessive skin dryness be managed?

• Answer: Use alcohol-free lotions to moisturize skin, bathe less frequently, or avoid soap. Drink fluids to prevent dehydration and wear cotton clothing to prevent irritation.

Flashcard 6: Managing Acne

• Question: How should acne be managed to prevent infection?

• Answer: Keep skin clean, wash hair and skin with warm water and soap daily, avoid oily cosmetics, and never squeeze or pick at acne lesions to prevent infection and scarring.

Flashcard 7: Skin Protection From Sun Exposure

• Question: What are key steps in protecting skin from sun exposure?

• Answer: Apply a broad-spectrum sunscreen with SPF 30 or greater 15 minutes before sun exposure. Reapply after swimming or sweating. Wear sun-protective clothing and limit sun exposure, especially from 10 a.m. to 4 p.m.

Flashcard 8: Risks of Indoor Tanning

• Question: Why should indoor tanning be avoided?

• Answer: Indoor tanning increases the risk of skin cancer. Clients using indoor tanning should see a dermatologist annually to assess for malignant lesions.

Flashcard 9: Risk Factors for Skin Cancer

• Question: What are common risk factors for developing skin cancer?

• Answer: Risk factors include significant UV exposure, family history of melanoma, having 50 or more moles, atypical or large moles, light hair or eye color, and a history of severe sunburns in childhood.

Flashcard 10: Skin Self-Examination

• Question: How can clients perform a skin self-examination?

• Answer: Instruct clients to examine their skin regularly in a well-lit room with a mirror. Have a partner assist with hard-to-see areas. Notify their healthcare provider if any moles or lesions change size, color, or shape, or if a sore doesn’t heal.

Flashcard 11: Early Identification of Suspicious Lesions

• Question: Why is it important to identify suspicious skin lesions early?

• Answer: Early identification and treatment of suspicious lesions increase the chances of better outcomes. It is more effective to address them sooner than later.

Flashcard 12: Importance of Sunscreen

• Question: Why is it important to use sunscreen even for clients with darker skin tones?

• Answer: Although darker skin tones have more melanin, all clients should use sunscreen to prevent sun damage, premature aging, and skin cancer.