With Complete Solutions
What are the components of the integumentary system? correct answer: Skin, hair, nails, and sweat glands
What does the integumentary system show? correct answer: - Vital information about the patient's health status
- Reflects the patient's hydration, nutrition, and emotional status
What are risk factors for integumentary system? correct answer: - Nutritional Status
- Immobility
Pressure
Shearing forces
- UV exposure - natural and artificial
What are the health promotion strategies for skin? correct answer: - Educate client on features of a benign mole.
- Emphasize steps in skin self-examination.
- Educate clients about decreasing UV exposure - "Seek, Slip, Slap, Slop".
- What about tanning beds?
What are the ACBDEs of melanoma? correct answer: A asymmetry
B border
C colour
D diameter E evolution
What are examples of subjective data collection for skin? correct
answer: - Assessment of risk factors
Family history
Past history
Medications
Lifestyle, occupational
history, and personal
behaviours
- Important to ask about history of present illness
What specific questions would you ask?
What are the components of a comprehensive physical assessment of the skin? correct answer: - Inspection
- Palpation*
- Documentation of Examination Findings
If client has specific concern about skin, inspect area/lesion first and ask other questions second
What is done during an inspection of the skin? correct answer: -
If performing complete skin assessment, inspect all body areas
- Note overall skin appearance - colour and pigmentation
- Is colour consistent with genetic background?
- Are there abnormalities? (e.g., cyanosis, pallor, jaundice, erythema, edema)
- Inspect individual lesions
- Note if non-elevated, elevated, solid, fluid-filled
- Configuration, pattern, morphology, size, distribution and body
location
- Observe for growths, tumours or vascular lesions - Inspect any wounds or incisions
- Pressure Ulcers - stages (will be learned later in program)
- Burns - classified based on depth of tissue destruction and percentage of total body surface area (will be learned later in program)
- Inspect nails and hair
How do you identify a lesion: morphology, configuration, pattern, size, distribution colour, texture and body location correct answer: Identify
- Location of the lesion(s)
- Distribution of the lesions as localized, regional, or generalized
- Whether lesion is primary (appearing initially) or secondary (resulting from a change in a primary lesion)
- The shape of the lesion
- Margins (borders)
- Morphology: papule, plaque, pustule, bulla, macule etc
- Colour, pigmentation
- Texture, consistency
- Size
How do you preform palpation? (skin) correct answer: - Assess skin temperature, moisture and texture.
- Assess skin turgor (best place is below clavicle).
- Palpate lesions for tenderness, mobility, and consistency.
- Palpate hair and nails.
What are common skin lesions? correct answer: Pt. 2 correct answer: