Podcast
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?
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?
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)?
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?
What characteristics does a macular lesion have?
Which areas are especially important to keep clean and dry to prevent breakdown and other skin problems?
Which areas are especially important to keep clean and dry to prevent breakdown and other skin problems?
How may pallor present in a dark-skinned patient?
How may pallor present in a dark-skinned patient?
What advice would the nurse give an older adult patient to help protect aging skin?
What advice would the nurse give an older adult patient to help protect aging skin?
Which type of infection may appear as fluorescent under a Wood light?
Which type of infection may appear as fluorescent under a Wood light?
Which instructions would the nurse include when educating the public about important sun exposure precautions?
Which instructions would the nurse include when educating the public about important sun exposure precautions?
Which instruction would the nurse include about sunscreen usage?
Which instruction would the nurse include about sunscreen usage?
What instruction would the nurse give to a patient who has been prescribed topical therapy?
What instruction would the nurse give to a patient who has been prescribed topical therapy?
What treatment would the nurse include when caring for a skin tear?
What treatment would the nurse include when caring for a skin tear?
Which term describes brown spots associated with normal age-related changes in the skin?
Which term describes brown spots associated with normal age-related changes in the skin?
Which nursing interventions may help prevent skin tears?
Which nursing interventions may help prevent skin tears?
Which patient statement indicates the need for further education about skin and sun protection?
Which patient statement indicates the need for further education about skin and sun protection?
Which diagnostic test or procedure can be used in the assessment of the integumentary system?
Which diagnostic test or procedure can be used in the assessment of the integumentary system?
Which skin self-assessment finding should the patient report immediately?
Which skin self-assessment finding should the patient report immediately?
What instruction would the nurse include when educating an older patient about preventing skin cancer?
What instruction would the nurse include when educating an older patient about preventing skin cancer?
Which cultural or ethnic factor should the nurse consider when performing a skin assessment?
Which cultural or ethnic factor should the nurse consider when performing a skin assessment?
What term describes dry, white patches related to psoriasis?
What term describes dry, white patches related to psoriasis?
What intervention would the nurse include when treating a patient with multiple skin tears?
What intervention would the nurse include when treating a patient with multiple skin tears?
What change in the skin can result from overexposure to ultraviolet (UV) rays?
What change in the skin can result from overexposure to ultraviolet (UV) rays?
What recommendation would the nurse give an older adult patient complaining of dry skin?
What recommendation would the nurse give an older adult patient complaining of dry skin?
Which mechanism of heat loss depends on evaporation?
Which mechanism of heat loss depends on evaporation?
What term would the nurse use to document a skin lesion that is elevated, flesh-colored, and solid about 0.7 cm in diameter?
What term would the nurse use to document a skin lesion that is elevated, flesh-colored, and solid about 0.7 cm in diameter?
Which term would the nurse use to describe a skin lesion 0.4 cm in diameter and filled with purulent fluid?
Which term would the nurse use to describe a skin lesion 0.4 cm in diameter and filled with purulent fluid?
Which type of skin lesions are often associated with varicella (chickenpox)?
Which type of skin lesions are often associated with varicella (chickenpox)?
An older adult may demonstrate increased cold sensitivity as a result of which age-related change?
An older adult may demonstrate increased cold sensitivity as a result of which age-related change?
During the change of shift report, what characteristic would the oncoming nurse likely observe with papular lesions?
During the change of shift report, what characteristic would the oncoming nurse likely observe with papular lesions?
What substances occur when ultraviolet (UV) rays of the sun strike the skin?
What substances occur when ultraviolet (UV) rays of the sun strike the skin?
What precaution should a student nurse use when touching a patient's skin to prevent self-contamination or transmission of organisms?
What precaution should a student nurse use when touching a patient's skin to prevent self-contamination or transmission of organisms?
In which age group would reduced elasticity and moisture of the skin be considered a normal assessment finding?
In which age group would reduced elasticity and moisture of the skin be considered a normal assessment finding?
Which term would the nurse use to document a skin lesion that is flat, red in color, and around 0.6 cm in diameter?
Which term would the nurse use to document a skin lesion that is flat, red in color, and around 0.6 cm in diameter?
What describes elevated, superficial solid lesions greater than 0.5 cm in diameter?
What describes elevated, superficial solid lesions greater than 0.5 cm in diameter?
What term would the nurse use to describe a skin lesion that is round, flat, and 0.4 cm in diameter?
What term would the nurse use to describe a skin lesion that is round, flat, and 0.4 cm in diameter?
Where would the nurse test the skin to check skin turgor?
Where would the nurse test the skin to check skin turgor?
What functions does the skin serve for the body?
What functions does the skin serve for the body?
What purpose does melanin serve for the skin?
What purpose does melanin serve for the skin?
What important function does skin serve for the body?
What important function does skin serve for the body?
Which tissue does not contain any blood vessels?
Which tissue does not contain any blood vessels?
What purposes does sebum serve in the body?
What purposes does sebum serve in the body?
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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.
Age-Related Skin Changes
- 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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