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NURS 302
chp. 11 Skin, hair, and nails
285
Nursing
Undergraduate 2
09/19/2011

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Term
what are the major components of the integumentary system?
Definition
skin, hair, nails
Term
what does the integumentary system consists of?
Definition
skin, hair, nails
the accessary structures such as the sweat and oil glands, hair and the nail
Term
how much does the largest organ of the body weigh?
Definition
9 lb (4.09 kg)
Term
what is the largest organ of the body?
Definition
skin
Term
how much square area is the skin
Definition
15-20 ft(4.5-6 m)
Term
every square inch of the skin contains how much blood vessels and nerves, sweat and oil glands, over 3 million cells are constantly dying and being replaced/
Definition
10-15 ft(3-4.5 m)
Term
the skin protects the body from?
Definition
heat
ultraviolet rays
trauma
invasion by bacteria
Term
the skin works with other body systems to do?
Definition
regulate body temperature
synthesize Vitamin D
store blood and fat
excrete body wastes
help humans sense the world around them
Term
the skin, hair and nails can reveal the status of the clients _____, ______,_____ and _____
Definition
nutrition
airway clearance
thermoregulation
tissue perfusion
Term
the skin, hair, and nails can reveal alterations in what
Definition
activity
sleep and rest
level of stress
self-care ability
Term
skin is very thin at birth and thickens throughout childhood. true or false
Definition
true
Term
what are the 2 distinct layers of the skin
Definition
epidermal
dermal
Term
the ______ glands which are located in the _____ layer, release secretion to lubricate the skin and to assist in temperature regulation
Definition
cutaneous glands
dermal layer
Term
the hair and nails are composed of _____ cells and serve to protect the skind and the ends of the fingers and toes
Definition
keratinized (hardened) cells
Term
where is the subcutaneous tissue(hypodermis) located
Definition
deep in the dermis
Term
anchors the skin to the underlying body structures
Definition
subcutaneous tissue (hypodermis)
Term
what are the 5 layers of the epidermis from deep to superficial
Definition
1. stratum basale(stratum germinativum)
2. stratum spinosum
3. stratum granulosum
4. stratum lucidum
5. stratum corneum
Term
where are new cells formed?
Definition
stratum basale(stratum germinativum)
Term
the new skin cells produced in the stratum basale consist of mostly of a fibrous protein called ____, which gives the epidermis its tough, protective qualities.
Definition
keratin
Term
about 25% of the cells in the stratum basale are ________
Definition
melanocytes
Term
the dermis consists of what 2 types of fibrers?
Definition
collagen
elastic fibers
Term
this fiber in the dermis gives the skin its toughness and enables it to resist tearing
Definition
collagen
Term
this fiber in the dermis give the skin its elasticity
Definition
elastic fibers
Term
which layer of skin is richly supplied with nerves, blood vessels and lymphatic vessels, and it is embedded with hair follicles, sweat glands, oil glands and sensory receptors
Definition
dermis
Term
loose connective tissue that stores approximately half of the bodys fat cells. thus it cushions the body against trauma, insulates the body from heat loss and stores fat for energy
Definition
subcutaneous tissue (hypodermis)
Term
the cutaneous glands are formed in the _____ and push deep into the ______
Definition
stratum basale (stratum germinativum)
dermis
Term
what are the 2 types of sweat (sudoriferous) glands?
Definition
eccrine
apocrine
Term
which sweat gland is more numerous and more widely distributed?
Definition
eccrine glands
Term
gland that produces a clear perspiration mostly made of water and salts, which they release into funnel shaped pores at the skin surface
Definition
eccrine glands
Term
this gland is found primarily in the axillary and anogenital regions
Definition
apocrine glands
Term
this gland produces a secretion made of water, salts, fatty acids, and proteins which is released into the hair follicles
Definition
apocrine gland
Term
when sweat from this sweat gland mixes with bacteria on the skin surface, it assumes a musky odor
Definition
apocrine
Term
what is the name for oil glands
Definition
sebaceous glands
Term
this gland is distributed over most of the body except the palms of teh hands and soles of the feet.
Definition
sebaceous glands (oil glands)
Term
what is sebum composed of? and where is it released
Definition
an oily sercretion composed of fat and keratin that is usually released into hair follicles
Term
what are the 7 major functions of the skin?
Definition
1. perceiving touch, pressure, temperature, and pain via the nerve endings
2. protecting against mechanical, chemical, thermal and solar damage
3. protecting against loss of water and electrolytes
4. regulating body temperature
5. repairing surface wounds through cellular replacement
6. synthesizing vitamin D
7. allowing identification through uniqueness of facial contours, skin and hair color and fingerprints
Term
what are the 6 major functions of the cutaneous glands?
Definition
1. excreting uric acid, urea, ammonia, sodium, potassium, and other metabolic wastes
2. regulating temp through evaporation of perspiration on the skin surface
3. protecting against bacterial growth on the skin surface
4. softening, lubricating and waterproofing skin and hair
5. resisting water loss from the skin surface in low humidity environments
6.protecting deeper skin regions from bacteria on the skin surface
Term
provides nutrition for the epidermis
Definition
dermis
Term
this gland decreases bacterial growth and decreases water loss from skin
Definition
sebaceous glands
Term
brownish pigment of skin
Definition
melanin
Term
is melanin genetically determined?
Definition
yes
Term
does melanin increase with sunlight?
Definition
yes
Term
this gives the skin a yellow color
Definition
carotene
Term
where is carotene found
Definition
in adipose tissue and horny layer
Term
yellow orange tinge to skin
Definition
carotenemia
Term
where is carotenemia best seen
Definition
face
palms
soles of feet
Term
what causes carotenemia
Definition
1. increased intake of foods high in carotene (eyes yolks, carrots and milk)
2. anorexia nervosa or endocrine disorders
Term
bright red, newly oxgenated blood
Definition
oxyhemoglobin
Term
increased visibility of oxyhemoglobin caused by dilation of vessels
Definition
erythema
Term
what causes erythema
Definition
fever, extreme warmth or extreme cold, local inflammation, allergy, alcohol
Term
oxyhemoglobin has a generalized redness of skin primarily to ____body
Definition
upper
Term
losing oxygenation
Definition
deoxyhemoglobin
Term
increased amounts of deoxyhemoglobin causes mottled bluish color of skin
Definition
cyanosis
Term
what causes cyanosis
Definition
poor circulation
low hemoglobin
decreased ability of blood to be saturated with oxygen or local vasoconstriction
Term
vestigial for humans
Definition
hair
Term
importat for cosmetic and psychological meaning
Definition
hair
Term
is the shaft of the hair visible?
Definition
yes it is visible
Term
where is new cells produced in hair
Definition
bulb
Term
which hair is fine, faint and covers most of the body except where? 
Definition

vellus hair

at the margins of the lips, nipples, the palms of the hands, soles of the feet and parts of the external genitals

Term
which hair is darker thicker and grows where? 
Definition

terminal hair

scalp, eyebrows, axillae, public area

face and chest for males

Term
nails consist of a hard ____
Definition
keratin
Term
where does new growth of nail occur
Definition
nail matrix
Term
end of fingers become enlarged, angle between skin and nail base is greater than 160 degrees
Definition
clubbing
Term
what are the causes of clubbing
Definition
long term poor perfusion or hypoxia(not getting enough oxygen). smoking, cirrhosis of liver
Term
[image]
Definition
clubbing
Term
infection and inflammation of cuticle
Definition
paronychia
Term
untreated hangnails
Definition
paronychia
Term
seperation of nail plate from nail bed
Definition
onycholysis
Term
trauma or infection of nail
Definition
onycholysis
Term
for older adults, chemicals access inner layers of skin more ____
Definition
easily
Term
in older adults, the loss of adipose tissue makes them more prone to ____
Definition
hypothermia
Term
in older adults, decreased numbers of sweat and sebaceous glands make their skin ___
Definition
dryer
Term
in older adults, there outer layer of skin thins making it ___
Definition
fragile
Term
in older adults, the loss of elastin/collagen causes _____ skin
Definition
sagging, wrinkled skin
Term
as you get older, the functioning melanocytes in your hair ____
Definition
decrease
Term
as you get older, your nails grow more ____
Definition
slowly
Term
as you get older, the nail surface gets ____
Definition
duller
Term
unclean skin can be due to what?
Definition
occupation
illness
disability
depression
Term
to check for alteraions in people with darker skin you check where on their body
Definition
lips
oral mucosa
sclera
palms
conjunctiva
Term
who is at the greatest risk for skin cancers
Definition
caucasian
Term
african americans and those with olive skin have increase for _____ scarring
Definition
keloid scarring
Term
________ have increased incidence of chronic inflammatory skin conditions
Definition
african americans
Term
can tattoss and body piercing be part of religious practice?
Definition
yes
Term
used by asian cultures as treatment to stimulate circulation and restore balance
Definition
coining, cupping, pinching
Term
practices leave welt, bruising and burns which often are mistaken for abuse
Definition
coining, cupping, pinching
Term
rubbing upper body with coins in symmetrical patterns. may leave severe bruising
Definition
coining
Term
heated glass cups applied to skin, circular/welts/burns are left on skin
Definition
cupping
Term
what are some common or concerning symptoms for the integumetary system
Definition
hair loss
changes in skin color or appearance
rash
moles(especially with new appearance)
Term
what are the laboratory tests you can do for skin? and what are the normal values?
Definition
Eosinophils 1-4%
IgE 0.002-0.2 mg/dl
Term
what are some diagnostic tests you can do for skin
Definition
gram stain and culture
immunostaining
patch tests
skin biopsy
skin scraping
tzanck test
Term
what is a diagnostic test for hair
Definition
trichogram-alopecia
Term
what is the diagnostic test for nails
Definition
biopsy
Term
subjective exam/health history questions in regards to skin includes?
Definition
"do you have any concerns about your skin today?"
common or concerning symptoms
previous history of skin disease(treatment &family history of skin disease)
changes in pigmentation
rash or lesion(localized, all over, treatment)
****older adults-diabetes, peripheral vascular disease
excessive dryness or moisture(seasonal or pruritus (itching))
excessive bruising(how, when did this begin)
****older adult-frequent falls
*****abuse
medications(prescriptions, over the counter, how long)
Term
subjective exam/health history questions in regards to hair and nails include?
Definition
hair loss
change in nails
environmental/occupational hazards
recreation(sunbathing, tanning beds)
occupation/hobbies(dyes, chemicals)
insect bites/ticks
exposure to animals/plants
***self care behaviors(self care products, nail/false nails, perform skin self exam)
Term
health promotion what are the education needs of patients?
Definition
-medications affect on skin
-decreased repair of aging skin
-decreased repair of skin with chronic illness(diabetes, circulatory disease)
-early detection of suspicious moles
-protective measures for skin care
-hazards of excessive sun exposure
Term
most common skin cancer
Definition
basal cell carcinoma
Term
______% of skin cancers are basal cell carcinoma
Definition
80%
Term
this skin cancer is least malignant, rarely metastasize
Definition
basal cell carinoma
Term
this skin cancer is shiny, translucent, grows slowly
Definition
basal cell carcinoma
Term
this skin cancer is over proliferation of new cells in basal layer
Definition
basal cell carcinoma
Term
_____% of skin cancer is squamous cell carcinoma
Definition
16%
Term
where is squamous cell carcinoma commonly found
Definition
scalp, ears, back of hands, lips
Term
does squamous cell carcinoma grow slowly or rapidly?
Definition
rapidly
Term
does basal cell carcinoma grow slowly or rapidly?
Definition
slowly
Term
does basal cell carcinoma metastasize?
Definition
rarely
Term
does squamous cell carcinoma metastasize
Definition
it may
Term
this skin cancer is crusted, scaly, ulcerated
Definition
squamous cell carcinoma
Term
_____% of skin cancer is malignant melanoma
Definition
4%
Term
does malignant melanoma grow slowly or rapidly
Definition
rapidly increases in frequency
Term
where does malignant melanoma rapidly spread to?
Definition
lymph and blood systems
Term
what is the ABCDE for screening moles for possible melanoma?
Definition
A-asymmetry
B-irregular borders, especially ragged, notched or blurred
C-for variation or change in color, especially blue or black
D-for diameter is greater than 6 mm or different from others, especially changing, itching or bleeding
E-for elevation or enlargement
Term
your risk for skin cancer was determined by the age____
Definition
18
Term
_________ are the most common CAUSE of skin cancer are most intense
Definition
ultraviolet B rays (UV-B)
Term
tattoos increase your risk for what?
Definition
skin infection
hepatitis C
HIV
Term
body piercing increase your risk for what?
Definition
skin infection
hepatitis C
HIV
abnormally scarring of area
Term
what is the best kind of light to use when doing physical examination
Definition
natural lightening bc artificial light often distorts colors
Term
where is jaundice best seen?
Definition
sclera
Term
what is diaphoresis
Definition
profuse sweating
Term
changes in temperature may indicate decrease in ____
Definition
perfusion
Term
shiny smooth skin may be caused by ____
Definition
poor circulation
Term
how do you check for mobility and turgor of the skin
Definition
lift fold of skin
Term
note ease with which it lifts up (_______) and speed with which it returns to place (________)
Definition
mobility
turgor
Term
what is it called when you have decreased turgor? and what does that indicate
Definition
tenting
dehydration, weight loss
Term
what characteristics of lesions should you note?
Definition
anatomic location and distribution
patterns and shapes
type of lesion(macules, papules, nevi, vesicle)
color
Term
what are the 3 patterns and shapes of lesions
Definition
annular
confluent
discrete
Term
lesions with a circular shape
Definition
annular
Term
lesions that run together
Definition
confluent
Term
lesions that are separate and discrete
Definition
discrete
Term
type of lesion that physical changes in the skin considered to be caused directly by the disease process. most often not specific to a single disease
Definition
primary lesion
Term
what are the primary lesions
Definition
1.macule and patch
2. papule and plaque
3. nodule and tumor
4. vesicle and bulla
5. wheal
6.pustule
7. cyst
Term

flat

nonpalpable

changes in the skin color

with less than 1 cm of

circumscribed border

Definition
macules
Term

flat,

nonpalpable

changes in the skin color

with larger than 1 cm of

irregular border

Definition
patch
Term

elevated,

solid palpable masses

smaller than 0.5 cm

with a circumscribed border

Definition
papules
Term

elevated,

solid palpable masses

 with circumscribed border

that have groups of papules that form lesions

larger than 0.5 cm

Definition
plaque
Term
freckles, measles, and petechiae are what
Definition
macules
Term
mongolian spots, port-wine stains, vitiligo and chloasma are what
Definition
patches
Term
elavated moles, warts and lichen planus are what?
Definition
papules
Term
psoriasis, actinic karatosis and also lichen planus are what
Definition
plaques
Term
elevated, solid, hard or soft palpable masses extending deeper into the dermis than a papule and have circumscribed borders and are 0.5-2 cm
Definition
nodules
Term
elevated, solid, hard or soft palpable masses extending deeper into the dermis than a papule and have irregular borders and are larger than 2 cm
Definition
tumors
Term
small lipoma, squamous cell carcinoma, fibroma, intradermal nevi are what
Definition
nodules
Term
large lipoma, carcinoma, and hemangioma are what
Definition
tumors
Term
elevated, fluid-filled, round or oval-shaped, palpable masses with thin, translucent walls and circumscribed borders and its smaller than 0.5 cm
Definition
vesicle
Term
elevated, fluid-filled, round or oval-shaped, palpable masses with thin, translucent walls and circumscribed borders and are larger than 0.5 cm
Definition
bulla
Term
herpes simplex/zoster, early chickenpox, poison ivy, and small burn blisters
Definition
vesicles
Term
contact dermatitis, friction blisters, large burn blisters
Definition
bullae
Term
elevated, often reddish area with an irregular border caused by diffuse fluid in tissues rather than free fluid in a cavity, as in vesicles
Definition
wheal
Term
insect bites and hives
Definition
wheal
Term
elevated, pus-filled vesicle or bulla with a circumscribed border
Definition
pustule
Term
acne, impetigo, and carbuncles (large boils)
Definition
pustules
Term
elevated, encapsulated, fluid-filled or semisolid mass originating in the subcutaneous tissue or dermis, usually 1 cm or larger
Definition
cyst
Term
may envolve from primary lesions. may be caused by external forces such as scratching, trauma, infection or the healing process
Definition
secondary lesion
Term
what are the secondary lesions
Definition
1. atrophy
2. erosion
3. lichenification
4. scales
5. crust
6. ulcer
7. fissure
8. scar
9. keloid
Term
this is a translucent, dry, paperlike, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin
Definition
atrophy
Term
striae, aged skin
Definition
atrophy
Term
wearing away of the superficial epidermis causing a moist, shallow depression.
Definition
erosion
Term
do erosions extend into the dermis?
Definition
no and bc they dont they heal without scarring
Term
stratch marks, ruptured vesicles
Definition
erosion
Term
rough, thickened, hardened area of epidermis resulting from chronic irritation such as stratching or rubbing
Definition
lichenification
Term
chronic dermatitis
Definition
lichenification
Term
shedding flakes of greasy, keratinized skin tissue
Definition
scales
Term
the color of scales may be what
Definition
white, grey or silver
Term
what is the texture of scales
Definition
may vary from fine to thick
Term
dry skin, dandruff, psoriasis and eczema
Definition
scales
Term
dry blood, serum, or pus left on the skin when vesicles or pustules burst.
Definition
crust
Term
what color is crust
Definition
red-brown,orange, or yellow
Term
large crusts that adhere to the skin surface are called what
Definition
scabs
Term
impetigo, eczema, herpes, or scabs following abrasion
Definition
crust
Term
deep, irregularly shaped area of skin loss extending into dermis or subcutaneous tissue.
Definition
ulcer
Term
decubitus ulcers (pressure ulcers), stasis ulcers, chancres
Definition
ulcer
Term
a linear crack with sharp edges extending into the dermis
Definition
fissure
Term
cracks at the corners of the mouth or in the hands, athletes foot
Definition
fissure
Term
flat, irregular area of connective tissue left after a lesion or wound has healed.
Definition
scar
Term
new scars may be what color
Definition
red or purple
Term
old scars may be what color
Definition
silvery or white
Term
healed surgical wound or injury, healed acne
Definition
scar
Term
elevated, irregular, darked area of excess scar tissue caused by excessive collagen formation during healing. it extends beyond the site of the original injury
Definition
keloid
Term
tinea corporis, pityrosea
Definition
annular
Term
urticaria
Definition
confluent
Term
molluscum
Definition
discrete
Term
longitudinal bands of pigment may be normal finding in people with ____ skin
Definition
darker
Term
people confined to bed are particulary susceptible to _____and _____
Definition
skin damage
ulceration
Term
_______ sores result when sustained compression obliterated arteriolar and capillary blood flow to the skin
Definition
pressure sores(decubitus ulcers)
Term
**the Braden Scale for Pressure Ulcer Prevention includes what areas of assessment of risks
Definition
sensory perception
activity level
mobility
nutritional status
friction
moisture
shear forces
Term
the lower the total score on the Braden scale for pressure ulcer prevention the _____ risk for pressure ulcers
Definition
lower
Term
to check patients for pressure ulcers you need to inspect skin that overlies what
Definition
sacrum
buttocks
greater trochanters
knees and heels
Term
to check patients for pressure ulcers you roll the patients onto one side to see ____ and ____
Definition
sacrum
buttocks
Term
body odor becomes stronger during heavy activity because of the increased excretion of ____
Definition
uric acid
Term
profuse sweating is a significant avenue for sodium chloride loss and may indicate the presence of a systemic disorder including _____
Definition
infectious disease with a fever
Term
decreased sweating increases the risk for what
Definition
heat stroke
Term
delayed healing or frequent skin infections may be a sign of ______ or ____
Definition
diabetes mellitus
inadequate nutrition
Term
rashes related to clothing, jewelry or cosmetics may be due to _____
Definition
contact dermatitis (a type of allergy)
Term
pruritus (itching) increases with age. it is usually due to dry skin, which may in turn be caused by what
Definition
excessive bathing or use of harsh skin cleansers
Term
at birth, the newborns skin is typically covered with ______, a white, cheese-like mixture of sebum and epidermal cells
Definition
vernix caseosa
Term
decrease in skin mobility caused by an accumulation of fluid in the intercellular spaces
Definition
edema
Term
makes the skin look puffy, pitted and tight
Definition
edema
Term
when the nurse notes that the pregnant females clients face has hyperpigmented patches, the nurse teaches the client that this normal manifestation of pregnancy is referred to as what
Definition
chloasma
Term
what % of pregnant woman develop chloasma
Definition
70%
Term
some pregnant woman may get a dark line called a ______ running from the umbilicus to the pubic area, increased pigmentation of the areolae and nipples, and darkened moles and scars.
Definition
linea nigra
Term
a client is hospitalized for congestive heart failure. the nurse is assessing the clients degree of edema. the nurse documents that the client has deep edema. which numeic description could the nurse use to describe this edema
Definition
+4 (8 mm)
Term
what is the term for stretch marks
Definition
striae gravidarum
Term
this is common in infants and will disappear within the first few weeks of birth. but it is areas of tiny white facial papules which are called
Definition
milia
Term
what are milia caused by
Definition
due to sebum that collects in the opening of hair follicles
Term
these markings may include stork bites, which are irregular red or pink patches found most commonly on the back of neck. they disappear within a year of birth
Definition
vascular marking
Term
gray, blue, or purple spots in the sacral and buttocks areas of newborns
Definition
mongolian spots
Term
loss of color in skin due to the absence of oxygenated hemoglobin.
Definition
pallor
Term
pallor is widespread but where is it most apparent
Definition
face, mouth, conjuctive and nails
Term
the nurse must be alert for the possibility of impending shock if
Definition
client has pallor accompanied with a drop in blood presure, increased pulse and respirations and marked anxiety. if these cues are present, a physican should be consulted immediately
Term
certain medications can do what to hair
Definition
change the texture of the hair or lead to hair loss
Term
oral contraceptives may do what to hair
Definition
change the hair texture of rate of hair growth
Term
drugs used in the treatment of circulatory disorders and cancers may do what to hair
Definition
result in a temporary generalized hair loss over the entire body
Term
when you shave your legs, face or under arms, pluck eyebrows or facial hair it can cause trauma to the skin. use of unclean equipment can contaminate the skin. plucking leaves an open portal for bacteria and may lead to infection if ______ technique is not used
Definition
aseptic
Term
swimming regularly in the salk water or chlorinated pools can do what to your scalp and hair?
Definition
can dry the scalp and hair and may cause increased dandruff
Term
ridged, brittle, split or peeling fingernails may be caused by
Definition
protein or vitamin B deficiencies
Term
newly acquired dark longitudinal lines on the nail may indicate what
Definition
nevus or melanoma in the nail root. or maybe caused by medication including antiretrovirals
Term
dark lines in the nail may be normal in dark skinned clients. true or false
Definition
true
Term
when assessing the nails, whats the rationale for asking "have you been ill recently?"
Definition
because some cancer, heart disease, liver disease, anemia and other illnesses can cause various changes in the nails such as grooves, ridges or discoloration
Term
clients who have been treated with the antiviral drug zidovudine(retrovir, AZT) can develop what on their fingernails
Definition
dark longitudinal lines
Term
prolonged use of nail polish may ______. some clients may also have an allergic reaction to nail polish. use of artificial nails may encourage growth of _____ or damage ____
Definition
dry or discolor the nails
fungi or damage the nail plate
Term
whats the rationale for asking "do you spend a great deal of time at work or at home with your hands in the water?"
Definition
because bacterial and fungi infections of the cuticles may occur in people who submerge their hands in water for long periods
Term
what are some nail changes that occur during pregnancy
Definition
brittleness, formation of grooves, or onycholysis(separation of the nail from the nail bed)
Term
what are the risk factors for skin cancer?
Definition
sun sensitivity difficulty tanning history of prolonged sun exposure use of tanning beds diseases in which immunosuppression occurs history of skin cancer occupational exposure to some chemicals such as coat tar
Term
additionally, the national cancer institute (NCI) described the _____ tool as a method, when used in combination with physical examination, to calculate the risk for development of melanoma.
Definition
melanoma risk assessment tool
Term
the tool includes questions about age, gender, race, history of sunburn, geography, sun exposure, and moles
Definition
melanoma risk assessment tool
Term
when you are assessing capillary refill, you palpate the nail by pinching the nailbed and briskly releasing. blood should return in ____
and color should return ______ in healthy nails
Definition
blood should return in less than 2 sec
color should return instantly
Term
if you do the capillary refill and the nail bed appears blue, and color return is sluggish in clients with
Definition
cardiovascular or respiratory disorders
Term
which electrolytes are lost by individuals who are diaphoretic?
Definition
sodium chloride
Term
a client with diabetes should be asked about which problem during skin, hair and nail assessment
Definition
sores that do not heal
Term
what is the name of the technique to assess clubbing
Definition
schamroth technique
Term
list abnormal vascular lesions
Definition
hemangioma
port-wine stain
spider angioma
venous lake
petechiae
purpura
ecchymosis
hematoma
polycyclic
zosteriform
basal cell carcinoma
squamous cell carcinoma
malignant melanoma
kaposi sarcoma
Term
what are some common skin lesions
Definition
tinea
measles(rubeola)
german measles(rubella)
chickenpox (varicella)
herpes simplex
psoriasis
contact dermatitis
eczema
impetigo
Term
** skin TEXTURE is best assessed by the nurse using the dorsal surface of the finger. true or false
Definition
FALSE
Term
what are the abnormal hair findings
Definition
seborrhea
tinea capititis
alopecia areata
infection (folliculitis, furuncles)
hirsutism
Term
what are the abnormal nail findings
Definition
spoon nails
paranychia(infection of the cuticle)
onycholysis(separation of the nail bed)
beaus line
splinter hemorrhage
Term
when assessing edema, the nurse notes that a result of _____ indicates mild edema
Definition
1
Term
when you have a decrease in mobility from doing the skin fold that is usually
Definition
edema
Term
**the nurse observes that a 35 year old client skin is dry, rough and scaly. the nurse would suspect this may be related to?
Definition
hypothyroidism
Term
the nurse observes the presence of patchy, milk-white areas on the african american clients hands and face. the nurse would document this finding as
Definition
vitiligo
Term
do pregnant woman have an increase or decrease of secretion of sweat glands
Definition
increase
Term
**a 5 year old child is brought by the parents to the clinic. the parent expresses worry that the child has areas of hair loss. the nurse would ask if the child?
Definition
has a pet such as a dog or a cat
Term
**an 18 yr old client visits the clinic and verbalizes feelings of weakness. the clients skin color is pale and the nails are pale and slightly concave. the nurse should further assess the client for
Definition
anemia
Term
describe macule
Definition
flat
nonpalpable
changes in skin color
smaller than 1 cm
circumscribed border
Term
describe patch
Definition
flat
nonpalpable
changes in skin color
larger than 1 cm
irregular borders
Term
describe papule
Definition
elevated
solid
palpable masses
smaller than 0.5 cm
circumscribed border
Term
describe plaque
Definition
elevated
solid
palpable masses
groups of papules that form lesions larger than 0.5 cm
circumscribed border
Term
describe nodule
Definition
elevated
solid, hard or soft
palpable masses
deeper into the dermis than a papule
0.5 cm-2 cm
circumscribed border
Term
describe tumor
Definition
elevated
solid, hard or soft
palpable masses
extending deeper into the dermis than a papule
larger than 2 cm
irregular borders
Term
describe vesicle
Definition
elevated
fluid-filled
round or oval-shaped
palpable masses
thin, translucent walls
smaller than 0.5 cm
circumscribed borders
Term
describe bulla
Definition
elevated
fluid-filled
round or oval shaped
palpable masses
thin, translucent walls
larger than 0.5 cm
circumscribed
Term
describe wheal
Definition
elevated
reddish area
irregular border caused by diffuse fluid in tissues rather than free fluid in a cavity as in vesicles
size varies
Term
describe pustule
Definition
elevated
pus-filled
circumscribed border
size varies
Term
describe cyst
Definition
elevated
encapsulated
fluid-filled or semisolid mass
originating in the subcutaneous tissue or dermis
usually 1 cm or larger
Term
what are the risks for melanoma
Definition
personal or family history of melanoma
presence of moles that are atypical in growth or appearance and the presence of more than 50 moles
Term
bright red, raised lesion about 2 to 10 cm in diameter. it does not blanch with pressure. it is usually present at birth or within a few months of birth. typically, it disappears by age 10.
Definition
hemangioma
Term
what is the cause of hemangioma
Definition
a cluster of immature capillaries
Term
flat, irregularly shaped lesion ranging in color from pale red to deep purple-red. color deepens with exertion, emotional response, or exposure to extremes of temperature. it is present at birth and typically does not fade
Definition
port-wine stain
Term
what is the cause of port-wine stain
Definition
a large, flat mass of blood vessels on the skin surface
Term
where is the location/distribution of hemangioma
Definition
can appear on any part of the body
Term
where is the localization/distribution of port-wine stain
Definition
most commonly appears on the face and head but may occur in other sites
Term
what is the location of the hemangioma?
Definition
can appear on any part of the body
Term
what is the location of port-wine stain?
Definition
most commonly appears on the face and head but may occur in other sites
Term
flat, bright red dot with tiny radiating blood vessels ranging in size from a pinpoint to 2 cm.
Definition
spider angioma
Term
does spider angioma branch with pressure
Definition
yes
Term
what is the cause of spider angioma
Definition
telangiectasis(vascular dilation) caused by elevated estrogen levels, pregnancy, estrogen therapy, vitamin B deficiency or liver disease or it may not be pathologic
Term
what is the locatization/distribution of spider angioma
Definition
most commonly appears on the upper half of the body
Term
does hemangioma blanch with pressure
Definition
no
Term
flat, red or purple rounded "freckles" approximately 1-3 mm in diameter
Definition
petechiae
Term
minute hemorrhages resulting from fragile cappillaries, ______ are caused by septicemias, liver disease or vitamin C or K deficiency. they may also be caused by anticoagulant therapy
Definition
petechiae
Term
what is the localization/distribution of petechiae
Definition
most commonly appear on the dependent surfaces of the body (e.g. back, back, buttocks) but may occur elsewhere on the body. in the client with dark skin, the lesions may be seen in the oral mucosa and conjunctivae
Term
flat, reddish blue, irregularly shaped extensive patches of varying size
Definition
purpura
Term
bleeding, disorders, scurvy, and capillary fragility in the older adult(senile purpura) cause _____
Definition
purpura
Term
flat, irregularly shaped lesions of varying size with no pulsation. in light skin, it begins as a bluish purple mark that changes to greenish yellow. in brown skin, it varies from blue to deep purple. in black skin, it appears as a darkened area
Definition
ecchymosis
Term
does ecchymosis blanch wiht pressure
Definition
no
Term
release of blood from superficial vessels into surrounding tissue due to trauma, hemophilia, liver disease, or defiency of vitamin C or K causes _____
Definition
ecchymosis
Term
ecchymosis localization/distribution is where
Definition
occurs anywhere on the body at the site of trauma or presure
Term
raised, irregularly shaped lesion similar to an ecchymosis except that it elevates the skin and looks like a swelling
Definition
hematoma
Term
a leakage of blood into the skin and subcutaneous tissue as a result of trauma or surgical incision causes ____
Definition
hematoma
Term
hematoma localization/distribution can occur
Definition
anywhere on the body at the site of trauma, pressure or surgical incision
Term
spoon-shaped (koilonychia) ridges may be caused because of a deficiency in
Definition
iron
Term
poor wound healing/decubitius ulcer can be caused because of a defiency in
Definition
protein, calories, vitamin C, zinc
Term
follicular hyperkeratosis(goosebump flesh) may be caused because of a defiency in
Definition
vitamin A
Term
dry, scaly skin may be due to a defiency in
Definition
vitamin A, essential fatty acids, zinc
Term
photosensitive symmetric rash (pellagra) may be due to a defiency in
Definition
niacin
Term
bruising(purpura) may be due to a defiency in
Definition
vitamin C and K
Term
pinpoint hemorrhages(petechiae) may be due to a defiency in
Definition
vitamin C
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