Level I W2013

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Author:
amelia.m.norton
ID:
203799
Filename:
Level I W2013
Updated:
2013-03-02 19:38:00
Tags:
Integumentary
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Description:
WWCC Integumentary
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  1. Functions of the skin
    • Protects underlying tissues/organs
    • Maintains body temp
    • Excretes salts, H2O, organic wastes
    • Sensation to touch, pressure, pain, and temperature (sensors in Dermis)
    • Synthesizes Vitamin D for calcium use
    • Unique identifiers: birthmarks & fingerprints
  2. Skin changes with Aging
    • Epidermis thins, elastic fibers degenerate, 'sagging'
    • Loss of subcutaneous fat
    • Decreased perception of pain
    • Decreased circulation to skin
    • Diminished function of skin structures
  3. Skin of Older clients
    • thinner, more fragile, decreased turgor - skin tears
    • decreased elasticity - wrinkles, sagging
    • senile pruritus: most common skin affliction - dry itchy skin r/t reduction of sweat and oil glands
    • Senile lentigo: 'liver spots' - areas of localized hyperpigmentation
    • Keratoses: raised hyperpigmentation lesions - may become malignant
    • Skin tags, gray hair, thinning hair, thickened nails
  4. Health History & skin disorders
    • Age:
    • infants & toddlers - yeast, allergic, bacterial
    • children - bacterial, fungal, parasitic
    • 13-26 yrs: fungal infections, acne
    • 25-60 yrs: psoriasis, lupus, fungal infections
    • older adults: basal cell carcinoma
    • Sex: males have more skin pathology
    • Race: dark skinned-keloid formation, light skinned-skin cancers, psoriases
  5. Health History Assessment
    • Onset: when
    • Location: general/local
    • Quality: superficial/deep
    • Setting: work, home, play
    • Timing: day/night, menses, w/ certain foods
    • Associated manifestations: rashes, lesions, edema,systemic disease
    • Aggravating factors: chemicals, sunlight, stress, climate, clothes
    • Alleviating factors: diet changes, meds, baths, UV therapy
  6. Inspection of Sking
    • color
    • bleeding
    • ecchymosis
    • vascularity
    • moisture
    • temperature
    • texture
    • turgor
    • edema
  7. Cyanosis
    bluish tone through skin reflects reduced (deoxygenated) hemoglobin
  8. Pallor
    Paleness may be a sign of anemia, chronic disease, edema, or shock
  9. Erythema
    redness may be the result of increased blood flow from climatic conditions, local inflammation, infection, skin irritation, allergy
  10. Ecchymosis
    large, diffuse areas, usually black and blue in color, are caused by hemorrhage of blood into skin; are typically result of injuries
  11. Petechiae
    small, distinct pinpoint hemorrhages 2mm or less; can denote some type of blood disorder
  12. Jaundice
    yellow staining of the skin and white sclera usually caused by bile pigments
  13. Skin Assessment
    • Inspection: color, lesions, odor
    • Palpate: temp, texture, moisture
  14. Describing skin lesions
    • Lesion: pathological change in tissues
    • Location: start and spread
    • Quantity: grouping arrangement
    • Quality: morphology
  15. Types of Lesion
    • primary lesions: arise in previously normal skin, column 1
    • secondary lesions: arise from primary lesions usually as a result of rubbing, scratching, medication or healing, column 2
  16. Skin Infections
    • Bacterial: cellulitis, impetigo, MRSA
    • Fungal: athlete's foot, ringworm
    • Yeast: "thrush", candida
    • Viral: chicken pox, herpes simplex, herpes zoster, warts, Hand-Foot-Mouth
  17. Pruritus
    • itching, common symptom
    • increased itching = histamine action, warmth, vasodilation
  18. Diagnostic Procedures
    • Skin/wound culture & sensitivity
    • Potassium hydroxide exam & fungal culture - encourages hyphae growth
    • Scabies scraping
    • Wood's light exam - blacklight blue fungus
    • Patch testing: testing for allergens - stop corticosteroids/anti-histamines 48hr prior, hx of allergies, explain procedure, instruct in self-care, follow up appt
    • Biopsy
  19. Primary Lesions
    • arise in previously normal skin
    • column 1
    • generally non-palpable, may be slightly raised
    • less than 0.5cm
  20. Secondary Lesions
    • arise from primary lesions usually as a result of rubbing, scratching, medication, or healing
    • column 2
    • palpable
    • crusting over
  21. Bacterial infections
    • Etiology: Strep pyogenes, Staph aureus, Staph epidermis
    • Risk Factors: moisture, obesity, atopic dermatitis, chronic disease, systemic corticosteroids, antibiotics
    • Prevention: good hygiene practices and good health
  22. Cellulitis (bacterial)
    • skin infection into dermis & subQ fat
    • pain, edema, erythema
    • 1st Culture & sensitivity-strep pyogenes
    • Risks: malnourished, previous wound, diabetes, steroid therapy
    • ND: control itching, increase circulation, elevate, cleansing
    • Assess: personal hygiene, VS-temp, LOC, hypertension
  23. Impetigo (bacterial)
    • skin infection
    • very contagious: hand, neck, mouth
    • Pustular vesicles - honey crusted
    • Tx: bacitracin, antibiotic, ivory/dial soap, teaching
  24. MRSA (bacterial)
    • skin infection Staph aureus
    • Patho: superficial infection of upper portion of the follicle, small pustules at hair follicle (folliculitis) - deeper (furuncle/boil)
    • Very contagious: direct contact
    • vancomycin
  25. Athlete's foot (fungal)
    • tinea pedia (dermatophyte on the foot)
    • macerated tissue with scaling borders
    • very itchy & painful
    • Dx: potassium hydroxide
  26. Tinea corpis (fungal)
    • skin folds
    • Tx: clean washcloth/towel dry
    • expose to air
    • avoid tight clothes
    • "plaques"
  27. Candidiasis (yeast)
    • "pustule"
    • 'thrush' in children - mouth
    • white, cheesy
    • caused by candida or monilia yeast
    • invades axillae, under breasts, groin, perineal
    • Skin: exudative patches, beefy red, pruritic
    • S/Sx: itching, burning & irritation
  28. Chickenpox varicella
    • varicella zoster: systemic
    • papules
    • respiratory & touch - droplet precautions
  29. Herpes simplex 1, 2
    • 1. oral fever blisters or cold sores
    • 2. lesions of the genitals
    • red base with blister, spread easily
  30. Herpes Zoster - shingles
    • reactivation of chickenpox
    • contagious to those who have not had chickenpox
    • fever, burning, neuralgia
  31. Warts
    • HPV,
    • 12-16 yrs of age
    • epidermal thickening & keratinosis
    • 2/3 disappear in 2 yrs w/o trtmt
  32. Urticaria "hives"
    • allergic reaction
    • transient, pruritic patches or wheals w/ raised borders & blanched centers
    • 2-3 days
    • allergies to foods & drugs
    • 50% unknown cause
  33. Atopic dermatitis
    • allergic reaction
    • eczema: genetic predisposition to react to environmental antigens w/ inflammatory rash (often foods)
    • exacerbated by stress
    • lichenification - hypertrophied epidermis - leathery
  34. Contact dermatitis
    • allergic reaction
    • prior contact to sensitizing chemical or material
    • pruritic w/ red papules & plaques
    • takes shape of causative agent
  35. Seborrheic dermatitis
    • inflammation
    • appears as dandruff first
    • greasy scales on scalp, nasolabial folds
    • infants - 'cradle cap'
    • frequent in parkinson pt & other neurologic disorders as well as HIV/aids pt
  36. Psoriasis
    • chronic, hereditary autoimmune disorder w/ rapid skin cell production, improper shedding
    • S/Sx: pruritis, shedding, silvery plaques, extensor surfaces (elbows, knees)
    • cell turn over in 4 days instead of 28
  37. Nursing Diagnosis
    • Body Image Disturbance
    • Impaired Skin Integrity
  38. Stings, Lice, Scabies
    • Stings: scrape
    • Lice: itching, easily spread, feed on skin
    • Scabies: easily spread through touch, feed on blood, lesions
  39. Anti-infectives
    • antibacterial
    • antiviral
    • antifungal
    • antiparasitic
  40. Antiseptics
    • dakin solution
    • hibiclens
  41. anti-inflammatory
    corticosteroids
  42. antipruritics
    benadryl
  43. keratolytics
    salicylic acid
  44. stimulants/irritants
    coal tar
  45. acne products
    • tretinoin (retin a)
    • accutane (isotretinoin): req. to take to birth control pills
  46. Oral, Parenteral, Topical Medications
    • powder: promotes dryness, lubricates skinfolds; base for antifungal preps
    • lotion: oil & water emulsions; cooling & drying; useful in subacute pruritic eruptions
    • cream: oil & water emulsions; most common base for topical medications; lubricates & protects
    • Ointment: oil & water suspension; prevents dehydration and lubricant
    • Paste: mix of powder & ointment; needed drying effect
    • Gel: nongreasy propylene glycol & water
  47. Nursing intervention & learning needs for pt
    • Psychosocial impact: change in body image, social isolation, pain, decrease/loss of employment, costs of medications, hospitalization
    • Learning needs: cause of skin disorder, aggravating factors, proper use of prescribed medications, follow-up needed
  48. Emotional component of Skin lesions
    • body image disturbance r/t presence of lesions
    • hopelessness r/t chronicity of problem
    • self esteem disturbance r/t cosmetic effects
  49. Skin cancers
    • Basal cell carcinoma: most common skin cancer, esp. in caucasian males
    • Squamous cell carcinoma: tumor of squamous epithelium or mucous membranes, invasive
    • Malignant melanoma: esp. light skinned, blue eyed persons, often fatal
  50. Health promotion & prevention of skin disorders
    Risk factors: chemicals, pollutants, radiation, lack of personal hygiene habits, cosmetics, harsh soaps, long-term steroids or anticoagulants, nutritional deficiency, mod-severe emotional distress, injured areas have risk for infection, manicures/pedicures-hep B
  51. Actinic Keratosis
    pre-cancerous condition of thick, scaly patches of sun-damaged skin. solar or senile keratosis
  52. Basal cell carcinooma
    • rolled pearly borders
    • most common of human cancers
    • locally invasive, rarely metastasizes
    • develops in areas with high sun exposure
    • central ulceration
    • epithelial or dermis
    • loss of nose, ears, lips
    • Yellow, Red, Black
  53. Squamous cell carcinoma
    • begins in squamous cell, thin, flat, fish scale
    • look similar to basal cell
  54. Melanoma
    • Deadliest form of skin cancer 75% of all skin cancer deaths
    • tan, black, blue
    • irregular, circular borders
    • metastasize internally & externally
    • begin in melanocytes
  55. Melanoma - assess
    • Asymmetry - shape of one half does not match the other
    • Border - edges often ragged, notched, blurred, irregular in outline; pigment may spread into surrounding skin
    • Color - color is uneven, black, brown, tan, white, grey, red, pink, or blue
  56. Diameter
    there is a change in size, usually an increase. larger than 5mm
  57. Evolving
    change in any feature such as shape, size, color, elevation, itching, bleeding, or crusting
  58. Macule
    • circumscribed, flat area with a change in color, <5mm
    • freckles, petechiae, measles, flat mole, cafe au lait spot, vitiligo - complete depigmentation
  59. Papule
    • elevated, solid lesion, <5mm
    • wart, elevated moles, lipoma, basal cell carcinoma
  60. Vesicle
    • circumscribed, superficial collection of serous fluid, <5mm
    • chickenpox, shingles, second degree burn
  61. Plaque
    • circumscribed, elevated, superficial, solid lesion >5mm
    • psoriasis, seborrheic & actinic keratoses
  62. Wheal
    • firm, edematous, irregularly shaped area, diameter variable
    • insect bite, urticaria
  63. Pustule
    • elevated, superficial lesion filled with purulent fluid
    • impetigo
  64. Fissure
    • linear crack or break from the epidermis to dermis, dry or moist
    • athlete's foot, cracks at corner of mouth
  65. Scale
    • excess, dead epidermal cells produced by abnormal keratinization and shedding
    • flaking skin after drug reaction or suburn
  66. Scar
    • abnormal formation of connective tissue that replaces normal skin
    • surgical incision, healed wound
  67. ulcer
    • loss of epidermis and extending into dermis; crater-like; irregular shape
    • pressure ulcer, chancre
  68. Atrophy
    • depression in skin resulting from thinning of epidermis or dermis
    • aged skin, striae
  69. Excoriation
    • area in which epidermis is missing, exposing the dermis
    • abrasion, scratch

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