Adult Health Test 1 Integumentary part 1

Integumentary System Assessment

• Assess patients with integumentary issues about skin lesions or rashes.
• Inquire about onset, duration, pain, itching, paresthesia, recent skin color changes, sun exposure, and family skin cancer history.
• Macule: Flat, circumscribed, color change, <1 cm. Examples: freckles, flat moles, petechiae.
• Papule: Elevated, small lesion, raised, similar to a macule.
• Patch: Flat, irregular, >1 cm. Examples: Vitiligo, port wine stains, birthmarks, Mongolian spots, Café au Lait spots.
• Plaque: Firm, elevated, rough lesion. Examples: Psoriasis, keratosis.
• Wheal: Elevated, irregular, cutaneous edema, varying sizes. Examples: allergic reactions.
• Nodule: Elevated, deeper lesion, larger than a papule. Examples: erythema nodosum, lipomas.
• Tumor: Elevated, solid lesion, may or may not be demarcated. Examples: neoplasm, benign tumor, lipoma, hemangioma.
• Vesicle: Elevated, superficial, fluid-filled lesion. Examples: chickenpox, shingles.
• Bulla: Large vesicle, blister-like.
• Pustule: Vesicle-like, pus-filled. Examples: impetigo, acne.
• Cyst: Encapsulated lesion in dermis/subcutaneous, semi-solid content. Examples: sebaceous cysts.
• Telangiectasia: Irregular, red lines from capillary dilation, resembling spider veins.
• Scale: Thickened skin due to rapid cell proliferation. Examples: seborrheic dermatitis, drug reaction flaking, dry skin.
• Lichenification: Rough, thickened epidermis from chronic dermatitis. Often caused by scratching or irritation.
• Keloid: Irregularly shaped, elevated scar after trauma.
• Scar: Mark left on skin after injury.
• Excoriation: Epidermis loss, linear hollowed-out, crusted area. Examples: abrasions, scratches.
• Fissure: Deeper skin crack, often between toes (athlete's foot).
• Erosion: Epidermal portion loss, often after vesicle/bulla rupture.
• Pressure Injuries: Staged based on severity and depth of skin loss.
• Crust: Dried exudate scab from a wound.
• Atrophy: Thinning and aging of the skin.

Assessment of Dark Skin

• Dark skin has increased melanin, protecting against skin cancer.
• Easier assessment in lighter skin areas (palms, soles, forearms, abdomen, buttocks).
• Assess pallor in dark skin by checking: lips, mucous membranes, nail beds, conjunctiva (should be pink).
• Palpation may be needed to detect lesions.
• Pallor in dark skin can appear ashen or gray, yellowish in brown skin.
• Skin structure assessment is the same regardless of melanin content.

Chief Complaint Documentation

• Document exact lesion location, length, and width.
• Describe lesion appearance, type, characteristics (color, size).
• Use PQRST mnemonic: P-Provocative/Palliative; Q-Quality/quantity; R-Region; S-Severity/Symptoms; T-Time.
• Use ABCDE method for assessing skin lesions, especially moles: A-Asymmetry; B-Borders; C-Color; D-Diameter; E-Evolution.

Pressure Injuries Staging

• Stage 1: Non-blanchable erythema (redness) of intact skin.
• Stage 2: Partial-thickness skin loss involving dermis (abrasions, blisters, shallow craters).
• Stage 3: Full-thickness skin loss with subcutaneous tissue damage.
• Stage 4: Full-thickness skin loss with muscle, bone, or tendon exposure.
• Unstageable: Full-thickness loss, obscured by slough/eschar.
• Deep Tissue Injury: Non-blanchable, deep red/purple discoloration, different from surrounding skin.
• Key terms: Eschar (black/brown dead tissue), Slough (yellow/stringy moist tissue), Granulation tissue (new red healing tissue), Epithelialization (epithelial tissue replacement), Undermining (tissue erosion around wound edge), Tunneling (tunnel extending from wound).

Pressure Injury Assessment

• RN must stage pressure injuries.
• Measure length, width, and depth.
• Use clock face analogy for wound description (12 is always up).
• Document slough, eschar, granulation tissue, undermining, tunneling.
• Follow facility policies for assessment & documentation frequency.

Pressure Injuries

• Stage 1: Intact skin, non-blanchable redness, bony prominences, may appear different in dark skin.
• Stage 2: Partial-thickness skin loss, shallow crater, blister, not skin tears, tape burns, or excoriation.
• Stage 3: Full-thickness skin loss, subcutaneous damage, no bone/tendon/muscle involvement, undermining/tunneling possible.
• Stage 4: Full-thickness loss, bone/tendon/muscle exposure, slough/eschar/undermining/tunneling possible, high risk osteomyelitis.
• Unstageable: Full-thickness tissue loss, slough/eschar obscuring wound base, can't determine depth until removed.
• Deep Tissue Injury: Purple/maroon discolored intact skin, firm/mushy/boggy/warm/cool, painful, different from surrounding skin.
• Treatment: Nutritional support (protein, Vitamin C, Zinc), turning every 2 hours, pressure-relieving mattress/float heels, skin protectants, avoid massaging red areas, keep skin clean, leave stable heel eschar untreated.
• Wheelchair Users: Reposition every hour, encourage self-repositioning every 15 minutes.

Herpes Simplex Type 1

• Vesicles at lip/mouth/nose corners, cold sores/fever blisters.
• Subjective Data: Fatigue, mouth itching.
• Objective Data: Edematous, erythematous lip area, vesicle development, ulcers, crusting ulcers, burning pain after lesion rupture.
• Spread: Can spread to eyes, outbreaks often associated with illness/infection.
• Self-limiting: Resolves alone, recurrent outbreaks possible.