Chapter 42 - Skin Tear Classification Flashcards
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Questions and Answers

The Payne-Martin, STAR Skin Care, and International Skin Tear Advisory Panel (ISTAP) classification systems identify skin tears in which of the following categories?

  • A skin tear without tissue loss in which the edges can be realigned
  • A skin tear with partial tissue loss in which the edges cannot be realigned
  • A skin tear with complete tissue loss in which the epidermal flap is missing
  • All of the above (correct)

    • What does the 'A' of the ABCD assessment method refer to in relation to skin lesions?

    Symmetry

    Skin lesions known as vesicles typically have a diameter of how many centimeters (cm)?

    Less than 0.5 cm

    What characteristics does a macular lesion have?

    <p>Small, flat, discolored spot or patch on the skin</p> Signup and view all the answers

    Which areas are especially important to keep clean and dry to prevent breakdown and other skin problems?

    <p>The axilla and under the breasts</p> Signup and view all the answers

    How may pallor present in a dark-skinned patient?

    <p>Ashen-gray tone to the skin</p> Signup and view all the answers

    What advice would the nurse give an older adult patient to help protect aging skin?

    <p>Avoid sun exposure from 10:00 am to 2:00 pm.</p> Signup and view all the answers

    Which type of infection may appear as fluorescent under a Wood light?

    <p>Erythrasma</p> Signup and view all the answers

    Which instructions would the nurse include when educating the public about important sun exposure precautions?

    <p>Reapply sunscreen because it can be removed by various factors.</p> Signup and view all the answers

    Which instruction would the nurse include about sunscreen usage?

    <p>Use sunscreen even on cloudy days if you expect to be outdoors for an extended period.</p> Signup and view all the answers

    What instruction would the nurse give to a patient who has been prescribed topical therapy?

    <p>Apply the medication directly to the surface of the affected area.</p> Signup and view all the answers

    What treatment would the nurse include when caring for a skin tear?

    <p>Petroleum-based ointment</p> Signup and view all the answers

    Which term describes brown spots associated with normal age-related changes in the skin?

    <p>Senile lentigines</p> Signup and view all the answers

    Which nursing interventions may help prevent skin tears?

    <p>Avoid wearing rings and bracelets.</p> Signup and view all the answers

    Which patient statement indicates the need for further education about skin and sun protection?

    <p>I use a tanning bed to avoid the sun's harmful rays.</p> Signup and view all the answers

    Which diagnostic test or procedure can be used in the assessment of the integumentary system?

    <p>All of the above</p> Signup and view all the answers

    Which skin self-assessment finding should the patient report immediately?

    <p>A papule that changes in size, shape, and color</p> Signup and view all the answers

    What instruction would the nurse include when educating an older patient about preventing skin cancer?

    <p>Report any changes in lesions.</p> Signup and view all the answers

    Which cultural or ethnic factor should the nurse consider when performing a skin assessment?

    <p>Darkly pigmented individuals will have areas that are darker than other parts of the skin.</p> Signup and view all the answers

    What term describes dry, white patches related to psoriasis?

    <p>Plaque</p> Signup and view all the answers

    What intervention would the nurse include when treating a patient with multiple skin tears?

    <p>Gently cleanse the tears with saline and cover with a petroleum-based ointment.</p> Signup and view all the answers

    What change in the skin can result from overexposure to ultraviolet (UV) rays?

    <p>Severe wrinkles</p> Signup and view all the answers

    What recommendation would the nurse give an older adult patient complaining of dry skin?

    <p>Apply skin moisturizer after bathing.</p> Signup and view all the answers

    Which mechanism of heat loss depends on evaporation?

    <p>Sweating</p> Signup and view all the answers

    What term would the nurse use to document a skin lesion that is elevated, flesh-colored, and solid about 0.7 cm in diameter?

    <p>Nodule</p> Signup and view all the answers

    Which term would the nurse use to describe a skin lesion 0.4 cm in diameter and filled with purulent fluid?

    <p>Pustule</p> Signup and view all the answers

    Which type of skin lesions are often associated with varicella (chickenpox)?

    <p>Vesicles</p> Signup and view all the answers

    An older adult may demonstrate increased cold sensitivity as a result of which age-related change?

    <p>Thinned skin and decreased sebaceous gland activity</p> Signup and view all the answers

    During the change of shift report, what characteristic would the oncoming nurse likely observe with papular lesions?

    <p>Small, solid elevation of the skin</p> Signup and view all the answers

    What substances occur when ultraviolet (UV) rays of the sun strike the skin?

    <p>Melanin</p> Signup and view all the answers

    What precaution should a student nurse use when touching a patient's skin to prevent self-contamination or transmission of organisms?

    <p>Standard Precautions</p> Signup and view all the answers

    In which age group would reduced elasticity and moisture of the skin be considered a normal assessment finding?

    <p>Older adult</p> Signup and view all the answers

    Which term would the nurse use to document a skin lesion that is flat, red in color, and around 0.6 cm in diameter?

    <p>Patch</p> Signup and view all the answers

    What describes elevated, superficial solid lesions greater than 0.5 cm in diameter?

    <p>Plaque</p> Signup and view all the answers

    What term would the nurse use to describe a skin lesion that is round, flat, and 0.4 cm in diameter?

    <p>Macule</p> Signup and view all the answers

    Where would the nurse test the skin to check skin turgor?

    <p>Chest</p> Signup and view all the answers

    What functions does the skin serve for the body?

    <p>All of the above</p> Signup and view all the answers

    What purpose does melanin serve for the skin?

    <p>Absorbs light and acts to protect tissue from ultraviolet light</p> Signup and view all the answers

    What important function does skin serve for the body?

    <p>Maintains water and electrolyte balance</p> Signup and view all the answers

    Which tissue does not contain any blood vessels?

    <p>Epidermis</p> Signup and view all the answers

    What purposes does sebum serve in the body?

    <p>Keeps the hair and skin soft and pliable; inhibits bacterial growth on the surface of the skin</p> Signup and view all the answers

    Study Notes

    Skin Tear Classification

    • Payne-Martin, STAR Skin Care, and ISTAP classify skin tears as:
      • Without tissue loss, edges can be realigned
      • With partial tissue loss, edges cannot be realigned
      • With complete tissue loss, epidermal flap missing

    ABCD Assessment Method

    • "A" stands for Symmetry in skin lesion assessment.

    Skin Lesion Types

    • Vesicles: Diameter less than 0.5 cm
    • Macular lesions: Small, flat, discolored spots

    Skin Care

    • Maintain cleanliness in high-risk areas like the axilla and under breasts to prevent skin problems.

    Skin Assessment in Dark-Skinned Patients

    • Pallor might appear as an ashen-gray tone.

    Sun Protection for Aging Skin

    • Advise older adults to avoid sun exposure from 10:00 AM to 2:00 PM.

    Skin Infections

    • Erythrasma may appear as fluorescent under Wood light.

    Sun Exposure Precautions

    • Always reapply sunscreen; protective clothing, hats, and sunglasses are essential.
    • Tanning booths greatly increase melanoma risk for individuals under 36.

    Education on Sun Exposure

    • Sunscreen is necessary even on cloudy days during extended outdoor activities.

    Topical Therapy Application

    • Medications should be applied directly to the affected area.

    Treatment for Skin Tears

    • Use petroleum-based ointments for treatment.
    • Brown spots, called senile lentigines, are normal.

    Prevention of Skin Tears

    • Strategies include avoiding jewelry, using lift sheets, ensuring good nutrition, and regularly moisturizing skin.

    Awareness on Tanning Beds

    • A statement claiming tanning beds avoid UV exposure indicates a need for further education.

    Integumentary System Assessment Techniques

    • Skin biopsy, culture and sensitivity, and Wood light inspection are key diagnostic tests.

    Skin Self-Assessment Reporting

    • Immediate reporting is needed for papules that change in size, shape, or color.

    Skin Cancer Prevention Education

    • Encourage older patients to report any changes in skin lesions.

    Cultural Considerations in Skin Assessment

    • Recognize that individuals with darker skin will have uneven pigmentation.

    Psoriasis and Skin Terminology

    • Dry, white patches associated with psoriasis are termed as plaques.

    Care for Multiple Skin Tears

    • Gently cleanse with saline and apply petroleum-based ointment.

    Effects of UV Exposure

    • Overexposure can lead to severe wrinkles.

    Moisturizing Dry Skin

    • Applying moisturizer post-bathing is recommended for older adults.

    Mechanism of Heat Loss

    • Sweating is a key mechanism for heat loss through evaporation.

    Documentation of Skin Lesions

    • Terms for skin lesions include:
      • Nodule: Elevated, flesh-colored, solid lesion (0.7 cm)
      • Pustule: Elevated, filled with purulent fluid (0.4 cm)
      • Macule: Round, flat lesion (0.4 cm)
      • Patch: Flat, red lesion (0.6 cm)
      • Plaque: Elevated, superficial, solid lesions (greater than 0.5 cm)

    Skin Turgor Testing

    • Skin turgor is assessed on the chest.

    Functions of the Skin

    • Regulates body temperature, protects from organisms, and shields underlying tissues.

    Role of Melanin

    • Absorbs light and protects skin tissue from UV damage.

    Skin's Importance

    • Maintains water and electrolyte balance.

    Avascular Tissue

    • The epidermis is the only layer of skin without blood vessels.

    Purpose of Sebum

    • Keeps skin and hair soft, pliable, and inhibits bacterial growth.

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    Description

    Test your knowledge on skin tear classifications as defined by the Payne-Martin and other systems in this informative flashcard quiz. Understand the differences between skin tears with varying tissue loss and how they are categorized. Perfect for students and professionals in the healthcare field.

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