Med-Surg Ch. 60 Assessment of Integumentary Function
The nurse is assessing a patient with a primary skin lesion called a macule. What does the nurse understand is a clinical example of this lesion?
Port-wine stains
Functions of the skin
Prevent water loss, dissipates heat, plays a role in vitamin D synthesis, and is the first line of defense to prevent infection
Wood's Light Examination
Provides an ultraviolet light that allows for the identification of certain infections - some fungal infections fluoresce green while certain bacterial infections fluoresce a coral-pink.
The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand of a patient that bleed when picked off. What does the nurse suspect that this patient may have?
Psoriasis
The nurse is assessing the fingernails of a patient at the clinic. The nurse observes pitting on the surface of the nail. What disorder is this finding indicative of?
Psoriasis
What are the two major types of skin glands?
Sebaceous and sebum glands
The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?
The skin is ashen gray and dull
Hypopigmentation
decrease in the melanin of the skin, resulting in a loss of pigmentation
Clubbing of the nails is usually a diagnostic sign of what?
hypoxia
Cyanosis is a LATE sign of what?
hypoxia
Hyperpigmentation
increase in the melanin of the skin, resulting in an increase in pigmentation
What does skin need to be exposed to sunlight to manufacture?
Vitamin D
What could develop from insect bites or urticaria (hives)?
Wheals
The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?
Conduction
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?
"Have you been eating a large amount of carotene-rich foods?"
How often is the epidermis almost completely replaced?
3 to 4 weeks
The nurse is caring for an adult patient with a normal body temperature. What should the nurse know would be the approximate insensible water loss per day in this patient?
600 mL/day
What is used to examine cells from blistering skin conditions (herpes zoster, varicella)?
A Tzanck smear - secretions placed on a slide
What is the subcutaneous tissue primarily composed of and what is its function?
Adipose tissue and temperature regulation
How to observe for jaundice?
By examining the sclerae and mucous membranes
The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing?
Carbon monoxide poisoning
What alone is NOT a reliable sign of hypoxia?
Cyanosis
What are the three layers of the skin?
Epidermis, Dermis, and Subcutaneous tissue
Patch testing
Helps to identify allergens by placing a patch of the allergen onto the skin, allowing prolonged contact of the allergen and the assessing the area for redness, itching, or blisters and pain.
The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?
Herpes zoster
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient?
Jaundice
What can be observed with an increase in serum bilirubin?
Jaundice
The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?
Keloid
A patient has contact dermatitis on the hand, and the nurse observes an area that this thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?
Lichenification
The epidermis is composed of three types of cells. What are they?
Melanocytes, Merkel cells, and Langerhans cells
A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?
Patch test
When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease?
Purplish cutaneous lesions
What are the major physical processes involved in loss of heat from body to the environment?
Radiation, Conduction, and Convection
The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?
Vesicle
Vitiligo
a localized or widespread condition characterized by destruction of the melanocytes the circumscribed areas of the skin, resulting in white patches
What is the term used to describe hair loss?
alopecia
Keratin
an insoluble, fibrous protein that forms the outer layer of skin
dermatosis
any abnormal skin condition
Petechia
pinpoint red spots that appear on the skin as a result of blood leakage into the skin
Plaques have a flat top and are seen in what?
psoriasis
Telangiectases
red marks on the skin caused by distention of the superficial blood vessels
erythema
redness of the skin caused by congestion of the capillaries
Hirsutism
the condition of having excessive hair growth
Melanin
the substance responsible for coloration of the skin
