NUR 2092 Health Assessment Exam 2 Study Guide

NUR 2092 Health Assessment Exam 2 Study Guide HEENT Skin

The Aging Adult

Skin Color and Pigmentation. Senile lentigines are common variations of hyperpigmentation.Commonly called liver spots, these are small, flat, brown macules (Fig. 12-21). These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure. They appear on the forearms and dorsa of the hands. They are not malignant and require no treatment.

Common variations occurring in the aging adult are acrochordons, or “skin tags,” which are overgrowths of normal skin that form a stalk and are polyp-like (Fig. 12-24). They occur frequently on eyelids, cheeks and neck, and axillae and trunk.

Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. One type, seborrheic keratosis, looks dark, greasy, and “stuck on” (Fig. 12-22). They develop mostly on the trunk but also on the face and hands and on both unexposed and sun-exposed areas. They do not become cancerous.Common Shapes and Configurations of Lesions ANNULAR, or circular, begins in center and spreads to periphery (e.g., tinea corporis or ringworm, tinea versicolor, pityriasis rosea).CONFLUENT, lesions run together (e.g., urticaria [hives]).DISCRETE, distinct, individual lesions that remain separate (e.g., acrochordon or skin tags, acne).GYRATE, twisted, coiled spiral, snakelike GROUPED, clusters of lesions (e.g., vesicles of contact dermatitis). LINEAR, a scratch, streak, line, or stripe. TARGET, or iris, resembles iris of eye, concentric rings of color in lesions (e.g., erythema multiforme). ZOSTERIFORM, linear arrangement along a unilateral nerve route (e.g., herpes zoster).POLYCYCLIC, annular lesions grow together (e.g., lichen planus, psoriasis).TABLE 12-4 Primary Skin Lesions The immediate result of a specific causative factor; primary lesions develop on previously unaltered skin. Macule Papule Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever. Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in epidermis. Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca).

Patch Plaque Macules that are larger than 1 cm. Examples: mongolian spot, vitiligo, café au lait spot, chloasma, measles rash. Papules coalesce to form surface elevation wider than 1 cm. A plateaulike, disk-shaped lesion. Examples: psoriasis, lichen planus. Nodule Wheal Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi. Superficial, raised, transient, and erythematous; slightly irregular shape from edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism. Tumor Urticaria (hives) Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although “tumor” implies “cancer” to most people. Examples: lipoma, hemangioma. Wheals coalesce to form extensive reaction, intensely pruritic.Vesicle Elevated cavity containing free fluid, up to 1 cm; a “blister.” Clear serum flows if wall is ruptured. Examples: herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis. Bulla Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; thin walled and ruptures easily.

Examples: friction blister, pemphigus, burns, contact dermatitis. Cyst Pustule

Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin.Examples: sebaceous cyst, wen. Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne. Line drawings © Pat Thomas, 2010. See Illustration Credits for source information. TABLE 12-5 Secondary Skin Lesions Resulting from a change in a primary lesion from the passage of time; an evolutionary change. NOTE: Combinations of primary and secondary lesions may coexist in the same person. Such combined designations may be termed papulosquamous, maculopapular, vesiculopustular, or papulovesicular. Debris on Skin Surface Crust Scale The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown,

honey, or yellow, depending on fluid ingredients (blood, serum, pus). Examples:

impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion.Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, micalike), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin. Break in Continuity of Surface Fissure Erosion Linear crack with abrupt edges; extends into dermis; dry or moist. Examples: cheilosis—at corners of mouth caused by excess moisture; athlete's foot. Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis. Ulcer Excoriation Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Examples: stasis ulcer, pressure sore, chancre. Self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Examples: insect bites, scabies, dermatitis, varicella. Scar Atrophic Scar After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change.Examples: healed area of surgery or injury, acne. The resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Example: striae. Lichenification Keloid Prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen). A benign excess of scar tissue beyond sites of original injury: surgery, acne, ear piercing, tattoos, infections, burns.16 Looks smooth, rubbery, shiny and “clawlike”; feels smooth and firm. Found in ear lobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma. Most common ages are 10-30 years; higher incidence in Blacks, Hispanics, and Asians.16 Line drawings © Pat Thomas, 2010. See Illustration Credits for source information. TABLE 12-

• Pressure Ulcer (Decubitus Ulcer) Pressure ulcers appear on the skin over a bony

prominence when circulation is impaired, e.g., when a person is confined to bed or immobilized. Immobilization impedes delivery of blood carrying oxygen and nutrients to the skin, and it impedes venous drainage carrying metabolic wastes away from the skin.This results in ischemia and cell death. Common sites for pressure ulcers are on the back (heel, ischium, sacrum, elbow, scapula, vertebra) or the side (ankle, knee, hip, rib, shoulder). Risk factors for pressure ulcers include impaired mobility, thin fragile skin of aging, decreased sensory perception (thus unable to respond to pain accompanying prolonged pressure), impaired level of consciousness (also unable to respond), moisture from urine or stool incontinence, excessive perspiration or wound drainage, shearing injury (being pulled down or across in bed), poor nutrition, infection. Knowledge of risk factors and prevention of pressure ulcers is far more easily accomplished than is treatment of existing ulcers. However, once pressure ulcers occur, they are assessed by stage, depending on the pressure ulcer depth28: Stage I Stage II Intact skin appears red but unbroken. Localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure). Dark skin appears darker but does not blanch. Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed. Stage III Stage IV Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon. Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue. Exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue). Once stage III or IV ulcers occur, wound size must be measured weekly to provide quantifiable data for wound healing. Use disposable rulers with mm and cm markings, and measure the greatest overall wound length. Then measure the greatest length perpendicular to the first number and multiply.41 See Illustration Credits for source information. TABLE 12-7 Lesions Caused by Trauma or Abuse Pattern Injury Pattern injury is a bruise or wound whose shape suggests the instrument or weapon that caused it (e.g., belt buckle, broomstick, burning cigarette, pinch marks, bite marks, or scalding-hot liquid). Inflicted scalding-water immersion burns usually have a clear border such as a glove or sock, indicating that the body part was held under water intentionally. Deformity results from an untreated fracture because the bone heals out of alignment. These physical signs, together with a history that does not match the severity or type of injury, suggest child abuse and warrant intervention (see Chapter 7).

Summary Checklist: Skin, Hair, and Nails Examination

1. Inspect the skin:

Color General pigmentation Areas of hypopigmentation or hyperpigmentation Abnormal color changes

2. Palpate the skin:

Temperature Moisture Texture Thickness Edema Mobility and turgor Hygiene Vascularity or bruising

3. Note any lesions:

Color

Shape and configuration Size Location and distribution on body

4. Inspect and palpate the hair:

Texture Distribution Any scalp lesions

5. Inspect and palpate the nails:

Shape and contour Consistency Color

• Teach skin self-examination

EARS-

Inspect with the Otoscope:

As you inspect the external ear, note the size of the auditory meatus. Choose the largest speculum that fits comfortably in the ear canal, and attach it to the otoscope. Tilt the person's head slightly away from you toward the opposite shoulder. This method brings the obliquely sloping eardrum into better view.Pull the pinna up and back on an adult or older child; this helps straighten the S-shape of the canal (Fig. 15-7).(Pull the pinna down on an infant and a child younger than 3 years [see Fig. 15-13]). Hold the pinna gently but firmly. Do not release traction on the ear until you have finished the examination and the otoscope is removed.How do you pull the pinna of a child to assess the ear?Remember to pull the pinna straight down on an infant or a child younger than 3 years. This method matches the slope of the ear canal.

TESTS:

Whispered Voice Test: Stand arm's length (2 feet) behind the person. Test one ear at a time while masking hearing in the other ear to prevent sound transmission around the head. This is done by placing one finger on the tragus and pushing it in and out of the