Lewis Ch. 22 Assessment of Integumentary System & NCLEX Qs

Androgen excess

Enlarged facial pores, male sex characteristics, acne, acceleration of coarse hair growth

Confluent

Merging together (e.g., urticaria [hives])

Inflammatory bowel disease

Mouth ulcers, erythema nodosum

Primary skin lesions?

Occur on previously unaltered skin Macules Papules Plaques Wheals Vesicles Pustules

Alopecia

Loss of hair (localized or general) Eitology: Heredity, friction, rubbing, traction, trauma, stress, infection, inflammation, chemotherapy, pregnancy, emotional shock, tinea capitis, immunologic factors

Peripheral vascular disease

Loss of hair on hands and feet. Delayed capillary filling. Dependent rubor (redness), pain

Ulcer

Loss of the epidermis, extending into the dermis. Crater-like, irregular shape Examples: pressure ulcer, chancre

Hirsutism

Male distribution of hair in women Etiology: Abnormality of ovaries or adrenal glands, decrease in estrogen level, familial trait

What are the functions of the integumentary system?

- Protect underlying body tissues - Barrier against bacteria/viruses, prevents water loss - Fat in SubQ layer insulates body - Melanin screens and absorbs UV light - Sensory perception - Controls heat regulation by vasoconstriction/vasodilation - Sebum/sweat lubricate - Synthesis of vit D occurs in epidermis - Delivery system for drugs

Gerontologic differences of integumentary system contd.

-Decreased proliferative capacity= Diminished rate of wound healing -Decreased immunocompetence= Increase in neoplasms Hair: -Decreased melanin and melanocytes= Gray or white hair -Decreased oil= Dry, coarse hair. Scaly scalp -Decreased density of hair= Thinning and loss of hair -Cumulative androgen effect; decreasing estrogen levels= Facial hirsutism, baldness Nails: -Decreased peripheral blood supply= Thick, brittle nails with diminished growth -Increased keratin= Longitudinal ridging -Decreased circulation= Prolonged return of blood to nails on blanching

What are the 11 functional health patterns Gordon?

1)Health perception -health management 2) Values-belief 3) Cognitive-perceptual 4) Nutritional-metabolic 5) Activity-exercise 6) Elimination 7)Sexuality/reproductive 8) Sleep-rest 9) Self perception-self concept 10) Coping-stress tolerance 11) Role-relationship

Atrophy

Depression in skin resulting from thinning of the epidermis or dermis Examples: aged skin, striae

Androgen deficiency

Development of sparse hair. Marked reduction in sebum production

Systemic lupus erythematosus

Discoid lesions, maculopapular semiconfluent rash (butterfly rash), alopecia, mouth ulcers

Discrete

Distinct individual lesions that remain separate (e.g., acne)

Chronic kidney disease

Dry skin, pruritus, uremic frost, pallor, bruises

Paget's disease

Eczematous patch of nipple and areola

Scar

Abnormal formation of connective tissue that replaces normal skin Examples: surgical incision, healed wound

Cystic fibrosis

Abnormal sweat gland function

Malabsorption syndrome

Acquired ichthyosis (dry, scaly skin)

Polycyclic

Annular lesions grow together (e.g., psoriasis)

Excoriation

Area in which epidermis is missing, exposing the dermis Examples: abrasion, scratch

Glucocorticoid excess (Cushing syndrome)

Atrophy, striae, epidermal thinning, telangiectasia, acne. Decreased subcutaneous fat over extremities. Thin, loose dermis. Impaired wound healing. Increased vascular fragility. Mild hirsutism. Excessive collection of fat over clavicles, back of neck, abdomen, and face

Vitamin B1 (thiamine) deficiency

Edema, redness of soles of feet

Dermatomyositis

Edema; purplish-red upper eyelids; scaly, macular erythema over knuckles

Mole (nevus)

Benign overgrowth of melanocytes Etiology: Defects of development; excessive numbers and large, irregular moles; often familial

Symmetric

Bilateral distribution

Inadequate oxygenation due to respiratory disease

Cyanosis

Papule

Elevated, solid lesion. <0.5 cm in diameter. If lesion is >0.5 cm in diameter, it is a nodule. Examples: wart (verruca), elevated moles, lipoma, basal cell carcinoma

Pustule

Elevated, superficial lesion filled with purulent fluid Examples: acne, impetigo

Primary syphilis

Chancre

Annular

Circular, begins in center and spreads to periphery (e.g., tinea corporis [ringworm])

Plaque

Circumscribed, elevated, superficial, solid lesion. >0.5 cm in diameter Examples: psoriasis, seborrheic and actinic keratoses

Macule

Circumscribed, flat area with a change in skin color. <0.5 cm in diameter. If lesion >0.5 cm, it is a patch. Examples: freckles, petechiae, measles, flat mole (nevus), café-au-lait spots, vitiligo (complete depigmentation)

Vesicle

Circumscribed, superficial collection of serous fluid. <0.5 cm in diameter Examples: varicella (chickenpox), herpes zoster (shingles), second-degree burn

Grouped

Clusters of lesions (e.g., vesicles of contact dermatitis)

Hyperpituitarism (acromegaly)

Coarsened skin, deepened lines. Increased oiliness and sweating, acne. Increased number of nevi, hyperpigmentation; hypertrichosis (excess hair growth)

Hypothyroidism

Cold, dry, pale to yellow skin. Generalized nonpitting edema. Dry, coarse, brittle hair. Brittle, slow-growing nails

Vitiligo

Complete absence of melanin (pigment) resulting in chalky white patch Etiology: Autoimmune, familial, thyroid disease

Diabetes mellitus

Erythematous plaques of shins, delayed wound healing, neuropathy, acanthosis nigricans (velvety, dark skin on the neck and in skin folds)

Miscellaneous [Wood's lamp (black light)]

Examination of skin with long-wave ultraviolet light causes specific substances to fluoresce (e.g., Pseudomonas fungal, infections, vitiligo). Nursing Responsibility- Before: Explain purpose of examination. Inform patient it is not painful. During: Darken room.

Scale

Excess, dead epidermal cells produced by abnormal keratinization and shedding Examples: flaking of skin after a drug reaction or sunburn

Hematoma

Extravasation of blood of sufficient size to cause visible swelling Etiology: Trauma, bleeding disorders

Tenting

Failure of skin to return immediately to normal position after gentle pinching Etiology: Aging, dehydration, cachexia

Wheal

Firm, edematous, irregularly shaped area. Diameter variable Examples: insect bite, urticaria

Secondary syphilis

Generalized skin lesions, alopecia

Tertiary syphilis

Gummas

Microscopic Tests [Potassium hydroxide (KOH)]

Hair, scales, or nails examined for superficial fungal infection. Specimen put on glass slide and 10%-20% concentration of KOH added Nursing Responsibility- Before: Instruct patient regarding purpose of test. During: Prepare slide.

Keloid

Hypertrophied scar beyond wound margins Etiology: Predisposition more common in African Americans

Varicosity

Increased prominence of superficial veins Etiology: Interruption of venous return (e.g., from tumor, incompetent valves, inflammation), commonly found on lower legs with aging

Hyperthyroidism

Increased sweating, warm skin with persistent flush, thin nails, alopecia. Fine, soft hair

Liver disease and biliary tract obstruction

Jaundice, itching, pigmentary abnormalities, alterations in nails and hair, spider angiomas, telangiectasia

HIV infection

Kaposi sarcoma, eosinophilic folliculitis

Ecchymosis

Large, bruise-like lesion caused by collection of extravascular blood in dermis and subcutaneous tissue Etiology: Trauma, bleeding disorders

Scleroderma

Leathery hardening and stiffness of skin

Venous ulcers

Leathery, brownish skin on lower leg; pruritus, concave lesion with edema. Scar tissue with healing

Localized

Limited areas of involvement that are clearly defined (confined to one area)

Zosteriform

Linear arrangement along a dermatome area (e.g., herpes zoster)

Fissure

Linear crack or break from the epidermis to the dermis. Dry or moist Examples: athlete's foot, cracks at corner of the mouth

Addison's disease

Loss of body hair (especially axillary), generalized hyperpigmentation (accentuated in folds)

Hypoparathyroidism

Opaque, brittle nails with transverse ridges. Coarse, sparse hair with patchy alopecia

Thromboangiitis obliterans (Buerger's disease)

Pallor or cyanosis, gangrene, ulceration

Anemia

Pallor, hyperpigmentation, pale mucous membranes, hair loss, nail dystrophy

Non-Hodgkin's lymphoma

Papules, nodules, plaques, pruritus

Vitamin C deficiency

Petechiae, purpura, bleeding gums

Rheumatic heart disease

Petechiae, urticaria, nodules, erythema

Petechiae

Pinpoint, discrete deposits of blood <1-2 mm in the extravascular tissues and visible through the skin or mucous membrane Etiology: Inflammation, marked vasodilation, blood vessel trauma, blood dyscrasia that results in bleeding tendencies (e.g., thrombocytopenia)

Hodgkin's lymphoma

Pruritus, sensitive skin

Clotting disorders

Purpura, petechiae, ecchymosis

Vitamin B2 (riboflavin) deficiency

Red fissures at corner of mouth, glossitis

Erythema

Redness occurring in patches of variable size and shape Etiology: Heat, certain drugs, alcohol, ultraviolet rays, any problem that causes dilation of blood vessels in the skin

Nicotinic acid (niacin) deficiency

Redness of exposed areas of skin of hand or foot, face, or neck; infected dermatitis

Cyst

Sac containing fluid or semisolid material Etiology: Obstruction of a duct or gland, parasitic infection

Deficiency of essential fatty acids

Scaly skin

Solitary

Single lesion

Biopsy (Shave)

Single-edged razor blade used to shave off superficial lesions or small sample of a large lesion. Provides thin specimen for diagnostic purposes Nursing Responsibility- Same as with punch biopsy

Gerontologic differences of integumentary system

Skin: - Decreased subcutaneous fat, muscle laxity, degeneration of elastic fibers, collagen stiffening= increased wrinkling, sagging breasts and abdomen, redundant flesh around eyes, slowness of skin to flatten when pinched (tenting) -Decreased extracellular water, surface lipids, and sebaceous gland activity= Dry, flaking skin with possible signs of excoriation caused by scratching -Decreased activity of apocrine and sebaceous glands= Dry skin with minimal to no perspiration, skin color uneven -Increased capillary fragility and permeability= Bruising -Increased focal melanocytes in basal layer with pigment accumulation= Solar lentigines (liver spots) on face and back of hands -Diminished blood supply= Decrease in rosy appearance of skin and mucous membranes. Skin cool to touch. Diminished awareness of pain, touch, temperature, peripheral vibration.

Cyanosis

Slightly bluish gray or dark purple discoloration of the skin and mucous membranes caused by excessive amounts of reduced hemoglobin in capillaries Etiology: Cardiorespiratory problems, vasoconstriction, asphyxiation, anemia, leukemia, and malignancies

Biopsy (Punch)

Special punch biopsy instrument of appropriate size used. Instrument rotated to appropriate level to include dermis and some fat. Suturing may or may not be done. Provides full-thickness skin for diagnostic purposes Nursing Responsibility- Before: Verify that consent form is signed (if needed). During: Assist with site preparation, anesthesia, procedure, and hemostasis. Properly identify specimen. After: Apply dressing, give postprocedure instructions to patient.

Microscopic Tests (Culture)

Test identifies fungal, bacterial, and viral organisms. For fungi, scraping or swab of skin performed. For bacteria, material obtained from intact pustules, bullae, or abscesses. For viruses, vesicle or bulla and exudate taken from base of lesion Nursing Responsibility- Before: Instruct patient regarding purpose and procedure. During: Properly identify specimen. Follow instructions for storing specimen if not immediately sent to laboratory.

Dermis

The dermis is made of three types of connective tissue: collagen, elastic fibers, and reticular fibers. Collagen forms the greatest part of the dermis. It is responsible for the skin's mechanical strength. The primary cell type in the dermis is the fibroblast, which produces collagen and elastin. Collagen is critical in wound healing.

Chronic sensory polyneuropathies Spinal cord trauma

Trophic changes in skin resulting from sensory denervation, pressure ulcers, anesthesia, paresthesias

Angioma

Tumor consisting of blood or lymph vessels Etiology: Normal increase in incidence with aging, liver disease, pregnancy, varicose veins

Gyrate

Twisted, coiled spiral, snakelike

Asymmetric

Unilateral distribution

Miscellaneous (Patch test)

Used to assess for allergic dermatitis and photoallergic reactions. Application of allergens to the patient's skin (usually on the back) for 48 hr. Test sites examined 48 hr later for a reaction, characterized by the presence of erythema, papules, vesicles, or all of these. Additional readings beyond 48 hr may be done. Nursing Responsibility- Before: Explain purpose and procedure to patient. After: Instruct patient that patches are left in place for 48 hr, during which time it is important not to wash the area or play vigorous sport because if the adhesive tapes peel off the process will have to be repeated. The patches should not be exposed to sunlight or other sources of ultraviolet (UV) light.

Jaundice

Yellow (in white patients) or yellowish brown (in African Americans) discoloration of the skin, best observed in the sclera, secondary to increased bilirubin in the blood Etiology: Liver disease, red blood cell hemolysis, pancreatic cancer, common bile duct obstruction

5. The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called a. wheals. b. papules. c. pustules. d. plaques.

a

6. To assess the skin for temperature and moisture, the most appropriate technique for the nurse to use is a. palpation. b. inspection. c. percussion. d. auscultation.

a

7. Persons with dark skin are more likely to develop a. keloids. b. wrinkles. c. skin rashes. d. skin cancer.

a

A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as a. petechiae. b. erythema. c. ecchymosis. d. telangiectasia.

a

The nurse is assessing a white patient's skin color for cyanosis. The best place for the nurse to assess this is the a. lips. b. legs. c. wrists. d. sclera.

a

The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient? a. Tiny purple spots on the skin b. Large ecchymotic areas on the skin c. Hyperkeratotic papules and plaques d. Small, raised red areas on the soles of the feet

a

Langerhans' cells

a type of dendritic cell. They are immunocompetent cells that are essential to recognize antigens. When they are depleted, the skin cannot initiate an immune response. The Langerhans' cells in bioengineered skin grafts have been removed to prevent graft rejection. In skin diseases such as psoriasis and sarcoidosis, there are decreased numbers of Langerhans' cells.

1. The primary function of the skin is a. insulation. b. protection. c. sensation. d. absorption.

b

9. Diagnostic testing is recommended for skin lesions when a. a health history cannot be obtained. b. a more definitive diagnosis is needed. c. percussion reveals an abnormal finding. d. treatment with prescribed medication has failed.

b

A nurse is obtaining a health history from a patient with a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask this patient? a. "Is your sleep interrupted by severe episodes of itching at night?" b. "Have you noticed any changes in the way sores or wounds heal?" c. "Do you have any skin lesions that have changed in size or shape?" d. "What changes if any have you noticed in your skin, hair, and nails?"

b

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. The nurse would document this finding as a(n) a. scar. b. fissure. c. atrophy. d. excoriation.

b

The nurse is administering medications to a patient. What medication taken by the patient is most likely to have an effect on the integumentary system? a. Diuretic b. Corticosteroid c. Benzodiazepine d. Calcium channel blocker

b

The nurse is performing an assessment of a patient with obesity. Inspection reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. What is most likely causing the odor? a. Ecchymosis b. Colonization by yeast or bacteria c. Age-related integumentary changes d. Atrophy of the skin under the abdominal folds

b

The patient has diffuse distribution of moles on the body and the nurse is preparing the patient for a punch biopsy of one of the moles. What is the benefit of doing a punch biopsy for this patient? a. It is used for a superficial lesion. b. It provides a full-thickness of skin. c. It is used for good cosmetic results. d. It is used because the lesion is too large to remove.

b

2. Age-related changes in the hair and nails include (select all that apply) a. oily scalp. b. scaly scalp. c. thinner nails. d. thicker, brittle nails. e. longitudinal nail ridging.

b, d, e

The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which locations should the nurse inspect for cyanosis (select all that apply.)? a. Patient's sclera b. Patient's nail beds c. Soles of the patient's feet d. Palms of the patient's hands e. Conjunctiva of the patient's eyes

b, e

8. On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called a. vitiligo. b. intertrigo. c. Nevus of Ota. d. telangiectasia.

c

A patient is admitted to the acute care facility with purpura. Which laboratory test would be most important to check in the patient? a. Urinalysis b. Serum electrolytes c. Coagulation studies d. White blood cell count

c

3. When assessing the nutritional-metabolic pattern in relation to the skin, the nurse questions the patient regarding a. joint pain. b. the use of moisturizing shampoo. c. recent changes in wound healing. d. self-care habits related to daily hygiene.

c

4. During the physical examination of a patient's skin, the nurse would a. use a flashlight in a poorly lit room. b. note cool, moist skin as a normal finding. c. pinch up a fold of skin to assess for turgor. d. perform a lesion-specific examination first and then a general inspection.

c

A patient with diabetes mellitus has been diagnosed with peripheral vascular disease. Which dermatologic manifestations should the nurse assess? a. Redness of exposed areas of the skin on the hand, foot, face, or neck b. Leathery, brownish skin on lower leg, pruritus, concave lesions with edema, scar tissue with healing c. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing d. Atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck

c

The nurse is assessing a patient's skin temperature, turgor, moisture, and texture. What is the best technique for the nurse to use to obtain the data? a. Inspection of skin color b. Examination for vascularity c. Palpation of skin with the hand d. Percussion of the skin on the back

c

The nurse performs a physical assessment on a dark-skinned African American patient who reports difficulty breathing. What is the best location for the nurse to assess for cyanosis in this patient? a. Lips b. Earlobe c. Conjunctiva d. Palm of hand

c

When assessing an older adult patient, the nurse observed general wrinkles, sagging breasts, and tenting of the skin; gray hair; and thick brittle toenails. What age-related changes can cause these changes in the integumentary system? a. Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails b. Decreased extracellular water, surface lipids, and sebaceous gland activity; decreased scalp oil; and decreased circulation c. Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply d. Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

c

Secondary skin lesions?

changes that take place in the primary lesion due to infection, scratching, trauma, or various stages of a disease Fissure Scale Scar Ulcer Atrophy Excoriation

A patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system? a. Warm, flushed skin; alopecia; thin nails b. General hyperpigmentation and loss of body hair c. Pale skin; pale mucous membranes; hair loss; nail dystrophy d. Cold, dry, pale skin; dry, coarse hair; brittle, slow-growing nails

d

A patient with hypothyroidism has developed carotenemia. The nurse should assess for improvement of this condition on which part of the patient's body? a. Face b. Chest c. Sclera d. Palms of hands

d

An adolescent is brought to the clinic by a parent for treatment of acne. What should the nurse assess the patient for to support the existence of acne? a. Ulcers b. Wheals c. Vesicles d. Pustules

d

An older adult patient is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration? a. The skin color over the nose and ears has a blue tint. b. The skin of the extremities is warm and dry to touch. c. Pressing the skin over the ankles causes pitting for 10 seconds. d. Pinching the skin under the clavicle causes tenting for 10 seconds.

d

The nurse is teaching a patient about diagnostic testing for allergic dermatitis. Which statement by the patient demonstrates a correct understanding of the teaching? a. "A blood test will confirm the presence of abnormal antibodies." b. "My skin cells will be stained and examined under the microscope." c. "The rash will be scraped with a razor blade and the flakes cultured." d. "I will return to have the substances removed and the areas evaluated."

d

Where are apocrine sweat glands found?

in the axillae, breast areolae, umbilical and anogenital areas, external auditory canals, and eyelids. They secrete a thick milky substance containing protein, carbohydrate, and other substances.5 The secretions are odorless. Odor occurs when skin surface bacteria alter the secretions. These glands enlarge and become active at puberty because of reproductive hormones.

Major cells in the epidermis?

keratinocytes (90%) and melanocytes (5%). Remaining cells are Langerhans' and Merkel cells.

Merkel cells

touch receptors found in the epidermis and involved in the sensation of light touch. They are used when feeling the texture of an object and determining what it is. Found in the fingertips and also in the lips, but they are also present in areas of hairy skin.

Where are eccrine sweat glands found?

widely distributed over the body, except on the lips, ear canals, nail beds, labia minora, glans penis, and prepuce. One square inch of skin contains about 3000 eccrine sweat glands. Their main function is to cool the body by evaporation, excrete waste products, and moisturize surface cells. Sweat is a transparent watery solution composed of salts, ammonia, urea, and other wastes.