Integument A&P
Which layer of the skin contains the keratin and melanocytes?
Epidermis.
Keratin - tough, fibrous protein.
Melanocytes - pigmentation
State at least two questions that pertains to the client's present skin health condition?
Do you have any problems with...?
Notice any changes with...?
Notice any itching, bruising, lumps, rashes, scars, open sores, or skin lesions?
Do you perform a self-assessment of moles or skin lesions?
How do you care for your ...?
State one example of an expected variation of hyperpigmentation.
Birthmarks
Sun damage
Pregnancy changes
occurs when melanin is increased in one area.
Hypopigmentation: scars, stretch marks, vitiligo (patchy areas lacking brown melanin)
State an expected finding/variation for skin temperature.
The skin should be as warm as the practitioner's hands; however, if the environment is cold, the extremities may be cold.
For an extremity in a cast or a history of circulation problems, the skin might be slightly cooler.
A nurse is preparing the items necessary for an integumentary exam. Which items will the nurse have on hand? (Select all that apply)
A. Penlight.
B. Gloves.
C. Stethoscope.
D. Ruler.
E. Reflex hammer.
A. Penlight
B. Gloves
D. Ruler
What are the clear, hard plates of keratin called?
Nails.
Hair = thin, flexible, elongated fiber composed of dead keratinized cells.
State at least two questions that pertains to the client's past skin health history.
History of...allergies, rashes, cancer, or other?
State two expected variations of skin texture and moisture as client(s) mature.
Acne
Wrinkles
Scars
Unexpected findings: velvety skin, roughness, dryness, flakiness, diaphoresis.
State one unexpected finding when it comes to skin temperature.
Hyperthermia: fever, inflammation, infection, trauma, or sunburn.
Hypothermia: cardiac arrest, shock, blood clot, prolonged time in cooler environments.
What is NOT the purpose of the integumentary system?
A. Protects the inner body.
B. Regulates temperature.
C. Provides a sensory perception.
D. Produces vitamin C.
D. Produces vitamin C.
Rationale: The integument system produces/synthesizes vitamin D from sun exposure and is necessary for which mineral?
Which layer of skin contains collagen, blood vessels, nerves, hair follicles, and sensory receptors?
Dermis.
State at least one question that pertains to the client's family history when it comes to the skin assessment.
Does your family have history of skin cancer?
State the ABCDE rule that is used for inspecting suspicious skin lesions.
A: Assymetry (shape)
B: Border (outline)
C: Color (variations of change)
D: Diameter (greater than 6 mm)
E: Evolve (rapid change)
F: Funny from others "ugly duckling"
State one unexpected finding of skin mobility and turgor.
Tenting: significant weight loss, severe dehydration
Edema: Central problem (kidneys, heart) -Generalized or both sides.
Infection or trauma - one location or area.
FYI: Edema can mask jaundice or cyanosis d/t skin stretching from fluid accumulation.
A client has a visible skin disorder from acne, a port-wine stain on the right cheek, and eczema. Which hypothesis is the client most at risk for?
A. Disturbed body image.
B. Knowledge deficit.
C. Acute pain.
D. Chronic sorrow.
A. Disturbed body image.
What is another name for hypodermis?
Subcutaneous tissue.
Loose connective tissues that stores adipose tissue for energy, aids in temperature regulation, skin cushion to minimize trauma, and allows other structure to move underneath the skin.
State at least two questions that pertains to the client's behavior (lifestyle) when assessing for skin conditions.
Discribe your stress, anxiety
What medications (herbal, prescribed or OTC) do you take
Diet changes, 24 hour dietary intake
Social relationships
Temperature extremes
Work environment (x-ray, radioisotopes, chemical exposure)
Gloves (other protective equipment)
Travel
Hobby or job with repetitive tasks
State an unexpected color variation and the possible cause when a nurse inspects skin color on a variety of clients.
Pallor: vasoconstriction, decreased tissue perfusion, lack of oxygen, or prolonged elevation, anemia, stress
Absence: Albinism, fungal infection
Cyanosis: cardiac or pulmonary, low hemoglobin; vasoconstriction, emotional stress
ruddy: (increased hemoglobin or capillary blood stasis) polycythemia vera (overproduction of RBC, granulocytes, and platelets)
erythema: inflammation, fever, allergy, emotions, cold exposure, alcohol, dependent position
Jaundice (increased bilirubin): liver disease, biliary obstruction, sickle cell anemia, pernicious anemia
carotenemia: excess carotene ingestion, anorexia nervosa, endocrine disorder (DM, myxedema, hypopituitarism)
Uremia (pale yellow): chronic renal d/t nitrogenous waste increase
*brown (melanin): sun exposure, pregnancy, birth control pills, addison's disease or pituitary tumor.
Explain how to palpate for edema.
1. At the edematous area, apply pressure for 3-4 seconds
2. Inspect the area once pressure is released.
3. Can be smooth without indentation = nonpitting OR
Indentation is present, determine the severity.
+1 = 2 mm,
+2 = 4 mm
+3 = 6 mm
+4 = 8+ mm
A nurse is caring for a client with a pressure injury. Select the appropriate interventions that the nurse should implement (Select all that apply).
A. Inspect the skin at least every 4 hours and PRN for breakdown.
B. Reposition the client with decreased mobility every 4 hours.
C. Elevate the head of bed, greater than 30 degrees. D. Remove sources of excess moisture.
E. Provide dietary supplements as ordered.
F. Rub the reddened area.
G. Follow facility guidelines and prescribed orders for dressing changes.
A, D, E, G
B: Every 2 hours max.
C. Less than 30 degrees to prevent shearing from sliding down
F: never rub, it will further compromise circulation & tissue destruction.
FYI: Use a lift or team to move clients up in bed, sliding will cause shearing.
State two functions of hair?
Insulate against temperature extremes, protect against ultraviolet and infrared rays, perceived movement or touch, protect eyes from sweat, and protect nasal passage from foreign particle.
State two questions that correlate directly with pain of the skin.
Describe your pain
Where? How often is it experienced? Long it lasts? Length of time you have had pain? Rating? Triggers? Relievers - effective?
Which of the following are risk factors for developing skin cancer? (Select all that apply).
A. Exposure to ultraviolet rays.
B. Family history of skin cancer.
C. 50+ moles.
D. Large or atypical moles.
E. Light or red hair/skin color.
F. Blistering sunburns.
G. Freckles = brown macules.
H. Immunosuppression
I. Certain Medications
A-I
State two unexpected findings with palpating nails
Color variations: Brown with linear streaks (mole, melanoma), bluish tinge (cyanosis), whitish nails (anemia, pallor)
Clubbed: (spongy, respiratory)
Jagged: unevenness (nailing biting or brittle)
Structure variations: pits (nutritional deficiency or acute illness), splinter hemorrhages (endocarditis)
Delayed cap refill: greater than 3 seconds = cardiovascular
A client calls the office complaining of skin irritation. Which statement is most appropriate for the nurse to make?
A. Use a mild soap and rinse thoroughly, apply lotion.
B. Ensure the water temperature is less than 120F.
C. Refrain from squeezing or picking.
D. Use alcohol-free and perfume-free products.
D. Use alcohol-free and perfume-free products.
A = best for skin dryness + alcohol-free lotion. B = prevent burns from hot water. C. = best for acne.