Health Assessment Final

• epidermis


  Outer layer of skin, made up of 5 layers of epidermis, new cells are constantly being made in this layer.
• stratum corneum

  outermost layer of epidermis; horny cell layer where new cells from the basal cell layer migrate & flatten and are constantly being shed and replaced
• stratum lucidom


  2nd layer of epidermis
• stratum granulosum


  3rd layer of the epidermis
• stratum spinosum


  4th layer of epidermis
• stratum germinativum


  deepest layer of epidermis; basal cell layer where new skin cells are formed. Keratin & Melanin are formed here
• melanocytes produce


  melanin which gives skin its color (brown tones to skin and hair)
• functions of epidermis


  contains specialized cells responsible for perception of pain, light touch, vibration, temp. It is the 1st part of the body to initiate an immune response (can detect foreign antigens). Thickness of epidermis remains constant throughout lifespan. Epidermis is avascular (nourished by blood vessels from dermis)
• dermis


  middle layer of skin. supports the epidermis. Consists of mainly connective tissue (collagen). Enables skin to resist tearing & allows it to stretch. Contains nerves, sensory receptors, blood vessels, lymphatics, hair follicles, sebaceous glands, sweat glands. Thinnest skin in eyelids; thickest skin in palms & soles of feet
• skin is

  thinnest at birth & gradually increases until 4th/5th decade of life. After this skin thickness declines. (men has greater thickness throughout lifespan due to greater amounts of androgens)
• subcutaneous (fat layer)


  Provides insulation for temp. control. Storage of caloric (fat) reserves. Cushioning against external forces/protection. Composed of mainly fat & connective tissue. Contributes to skin mobility
• functions of skin

  provides a barrier. Regulates body tmp. Synthesizes Vitamin D (which works w/ calcium). Sensory perception. Nonverbal communication (color, goosebumps, facial expressions). Identity (redness, scars, moles, what the color of their skin is can help identify the person). Wound repair. Excretion of metabolic wastes (urea, bile salts)
• brown skin pigment comes from

  melanin
• yellow-orange skin tones come from


  the pigment carotene
• red-purple skin tones come from


  underlying vascular bed (we lose this tone during circulation issues)
• hair

  an addition of the skin & protects from debris, invasion, provides insulation, sensory stimulation to the NS, contributes to gender identification
• vellus hair


  fine, short, hypopigmented, located all over body
• terminal hair


  darker & courser hair found on scalp, brows, eyelids
• nails


  highly vascular, grow at varying rates. Some systemic & infectious processes affect growth rate, thickness, shape
• assessing skin, hair, nails

  examine the upper extremities while client is sitting or recumbent (lying down). Remove stockings/socks, drape client to expose the entire lower extremity at once. Make side-to-side comparison to evaluate for variations. Inspect & palpate simultaneously (look first before touching). Wear gloves, have ruler/tape measure to measure size & depth/lesions, adequate lighting
• pallor

  paleness/absence of skin color since red-pink tones from oxygenated Hgb are lost & takes on color of connective tissue (collagen) which is mostly white. Lighter skin appears white. POC appear yellow-brown/ashen gray. Check face, conjunctiva, nail beds, palm, lips, mucous membrane. Usually indicates anemia/loss of blood flow, arterial insufficiency
• cyanosis

  bluish discoloration from decreased perfusion- lack of oxygen bound to Hgb, impaired venous return. Check nail beds, lips, mouth, skin. Lighter skin appears dusky blue (usually in nails). POC only severe cyanosis is apparent in skin. Check conjunctiva, oral mucosa, nail beds
• circumoral cyanosis


  cyanosis around the mouth; associated w/ Congestive Heart Failure/Chronic Obstructive Pulmonary Disease
• peripheral cyanosis


  cyanosis on the fingers and toes due to cold exposure, anxiety, or inadequate circulation w/ oxygenated blood.
• nail clubbing indicates


  chronic hypoxia (lack of oxygen)
• erythema

  intense redness of skin due to excess blood. Hyperemia - increased blood flow thru engorged arterioles such as an inflammation, fever, alcohol intake & blushing. Localized vasodilation. Check face, trauma, pressure sore areas. Lighter skin appears red, bright pink. POC appears purplish but difficult to see (palpate for warmth, taut/tight skin)
• jaundice


  NOT A NORMAL SIGN (however babies r usually born w it). Yellow colors that indicates rising amounts of bilirubin in the blood. Indicates liver dysfunction (temporary/chronic), red blood cell destruction. Lighter skin appears yellow-tinged, yellow in sclera. POC- check sclera, palms
• ecchymosis (bruising)


  large patch of capillary bleeding into the tissues. Blood products are reabsorbed then change color on the skin surface. They first are red/blue/purple then blue/green then yellow then brown to disappearing. Every few days bruises change colors.
• allergic skin eruptions come from these meds

  ASA/aspirin, Abx/antibiotics, Barbiturates, laundry detergent
• increased sunlight sensitivity/burn response come from these meds


  sulfonamides, tetracyclines, oral hypoglycemics
• hyperpigmentation comes from these meds


  antimalarials, antineoplastics, hormones
• moles

  note color (should be one color), size (should be uniform in size, <6mm = normal, >6mm = abnormal), shape, tenderness, bleeding, itching (if its tender to touch, itchy --> mole can be abnormal)
• self skin examination (SSE)

  helps patients identify potentially problematic skin issues through the detection of moles
• pressure ulcers stage 1


  Skin still intact, but doesn't blanch, only epidermis is reddened
• pressure ulcers stage 2


  Partial-thickness skin loss involving epidermis or dermis
• pressure ulcers stage 3


  Full-thickness skin loss involving damage or loss of subcutaneous tissue
• pressure ulcers stage 4


  Full-thickness skin loss with damage to muscle, bone, or supporting structures
• braden scale


  A tool for predicting pressure ulcer risk. Sensory perception, moisture (we want skin to be dry), activity, mobility (more immobile --> greater risk of pressure injury), nutrition (need protein for wound healing), friction & shear (we do not drag patients when we move them since they may be at risk for skin tears)
• lesions


  tissue destruction
• bulla

  Large blister containing watery fluid