Adult Health Test 1 Integumentary part 1

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Questions and Answers

What is a macule?

A lesion characterized by thickened skin due to rapid cell proliferation.

A raised lesion, greater than 1 cm in size.

An irregularly shaped lesion filled with fluid.

A flat, circumscribed area that is less than 1 cm and changed in color. (correct)

Which of the following best describes a wheal?

A flat lesion greater than 1 cm.

A deep, encapsulated lesion in the subcutaneous layer.

A firm, elevated, rough lesion.

An elevated, irregular shaped area of cutaneous edema. (correct)

Which example is correctly associated with a bulla?

It describes rough, thickened epidermis.

Examples include chickenpox and shingles. (correct)

It is a linear hollowed-out area due to an abrasion.

Implications include a neoplasm or benign tumor.

What distinguishes a papule from a macule?

A papule is raised, while a macule is flat and circumscribed. Signup and view all the answers

Which of the following skin lesions is characterized by being filled with pus?

Pustule Signup and view all the answers

Which of the following describes lichenification?

Rough, thickened epidermis due to chronic irritation. Signup and view all the answers

What type of skin lesion is commonly associated with allergic reactions?

Wheal Signup and view all the answers

Which of the following lesions is typically encapsulated and filled with semi-solid material?

Cyst Signup and view all the answers

What characteristic defines a Stage 1 pressure injury?

Intact skin with non-blanchable redness Signup and view all the answers

When assessing pallor in dark-skinned individuals, which area is most appropriate to examine?

Nail beds Signup and view all the answers

The abbreviation ABCDE is used in the assessment of skin lesions. What does the 'B' stand for?

Borders Signup and view all the answers

What does 'tunneling' refer to in the context of pressure injuries?

A tunnel extending from the wound Signup and view all the answers

Which nutritional component is important for the treatment of pressure injuries?

Vitamin C Signup and view all the answers

A patient presents with vesicles at the corner of the mouth. What is the likely diagnosis?

Herpes Simplex Type 1 Signup and view all the answers

What is a key feature distinguishing a Stage 3 pressure injury from a Stage 4 pressure injury?

Involves full-thickness skin loss Signup and view all the answers

What must be documented regarding a pressure injury's characteristics?

General appearance and dimensions Signup and view all the answers

Which term describes black or brown, dead tissue that feels like leather?

Eschar Signup and view all the answers

In a patient with a Stage 4 pressure injury, what is the greatest risk associated with this condition?

Osteomyelitis Signup and view all the answers

A patient who is a wheelchair user should be repositioned every how many hours to prevent pressure injuries?

Every hour Signup and view all the answers

To assess the location of a rash or lesion accurately, what is a necessary step?

Measure the length and width Signup and view all the answers

What condition can precede outbreaks of Herpes Simplex Type 1?

Illness or infection Signup and view all the answers

Study Notes

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.

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Description

This quiz focuses on assessing various integumentary issues, including skin lesions and rashes. You will learn to inquire about key symptoms and review visual examples from your textbook. Understanding different types of lesions is crucial for effective patient assessment.