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*Epidermis
-Outer layer, avascular (no BV, doesn't bleed)
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*Dermis
-hair, nails
- -Inner layer, contains nerves, sensory receptors, BV, lymphatics
- -Hair: VELLUS (fine, soft, non pigmented; covers body except palms, soles, umbilicus, glans penis, inside labia), TERMINAL (course, thick, pigmented; scalp, eyebrows, eyelashes, axillae, pubic, face&chest in males)
- -Nails
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*Dermis
-Eccrine gland
Produces sweat/perspiration (saline), matures at 2mos
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*Dermis
-Apocrine glands
- -Opens into hair follicles
- -Activated during puberty
- -Secrete fluid in response to stimuli & heat
- -Decomposition of apocrine sweat produces BO (action of bacteria in fluid)
- -Located in axillae, nipples, areolae, anogenital area, eyelids & external ears
- -Secretion dec w/ aging (more prone to overheating)
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*Dermis
-Sebaceous glands
- -Secretes sebum which lubricates skin & nails
- -Concentrated in scalp & face (absent on palms & soles)
- -Some conditions in adult and child are r/t overproduction of sebum (cradle cap, acne, seborrheic dermatitis)
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Subcutaneous Tissue
- -Adipose or hypodermis
- -Layer below the skin
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Skin Functions
- -Protect: against bacteria, fluid/electrolyte loss
- -Sensory perception: pain, touch, temp, pressure
- -Thermoregulation: due to sweat & fat insulation
- -Replaces cell in surface wounds (aides in wound repair)
- -Absorption&Excretion: metabolic wastes-sweat, lactic acid, urea
- -Renal failure-->uremic frost: kidneys can't excrete waste, urea seeps out through skin
- -Vit D production: compounds are converted into Vit D when UV light comes into contact w/ skin surface
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Subjective Data
- -Previous hx of skin dz, change in pigmentation
- -Change in mole size, color, shape
- -Xerosis (dryness), Seborrhea (oily skin), prutitis (common w/ age d/t xerosis, chronic illness)
- -Excessive bruising (abuse, clotting disorder, falls), rash, lesions
- -Medications: may cause skin eruptions, pruritis, photosensitivity (sunburn)
- -Alopecia (diffused, patchy, total hair loss), hirsutism (excess facial hair d/t inc androgen prod by adrenal glands)
- -Nail change, sun exposure, self care behaviors (sunscreen, soaps, cosmetics)
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*Objective data
-Inspect & Palpation
- *Integrate skin assessment during phys exam
- -Assess sun exposed areas (inc cancer risk), intertriginous areas for fungus (skin folds), feet (primarily in diabetics)
- -Identify body piercing and skin condition (for inflamm, infection)
- -Describe skin color: pinkish tan, fair (light); light to dark brown; olive
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*Objective data
-Localized color change
- -Vitiligo: absence of melanin pigment in patchy areas (more common in dark skinned)
- -Freckles: ephelides, small, flat, brown macules
- -Pigmented nevi: (moles) inspect for changes
- -Birthmarks: inspect for changes
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*Diffused color changes
-Pallor
- *white or lighter coloration; ashen gray w/ brown/black skin
- -Anxiety/fear (vasoconstriction 2° to SNS stimulation)
- -Cold/Cigarette smoking (peripheral vasoconstriction)
- -Shock (shunting blood from periphery to mjr organs)
- -Arterial insufficiency/anemia (dec blood supply to PV system)
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*Diffused color changes
-Erythema
- *Red, flushed appearance
- -Hyperemia: excess blood of superficial capillaries r/t fever, local inflamm, inc emotions (blushing)
- -Polycythemia (accumulation of RBC)
- -Venous stasis: venous system doesn't drain back to heart erythema
- -Carbon monoxide poisoning
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*Diffused color changes
-Cyanosis
- *Bluish, gray due to dec perfusion of tissues (tissue hypoxia)
- -Central Cyanosis: (very late sign of hypoxia) 5mg unoxygenated hgb 2° to cardio-pulmonary problems
- -may not be seen in anemia, may not be enough unoxygenated hgb to show color changes (if hgb = 10, then 1/2 must be oxygenated before cyanosis is seen--may die of hypoxia first)
- -Peripheral Cyanosis: 2° d/t vasoconstriction (exposure to cold)
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*Diffused color changes
-Jaundice
- *Yellow, icteric, rising amts of bilirubin in blood (byproduct of RBC breakdown)
- -1st seen in junction b/t hard & soft palate & in sclera
- -Clay colored stools, dark yellow urine (bilirubin normally excreted thru GI tract; in biliary obstruction, bilirubin absorbed then excreted in urine)
- -Later seen in skin (if can't break down, absorbed into skin; bili light (UV) helps breakdown)
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*Objective data
-Skin temp
- -Hypothermia: due to dec circulation; generalized, localized (peripheral arterial insufficiency)
- -Hyperthermia (heat); generalized (inc metabolic rate-hyperthyroidism, fever, heavy exercise), localized (inflamm, infection)
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*Objective data
-Moisture
- -Perspiration (normal sweating)
- -Diaphoresis (perfuse sweating)
- -Dehydration (dry skin & mucus membranes, thirst-late sign of dehydration)
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*Objective data
-Texture, thickness, edema, turgor, hygeine
- -Texture
- -Thickness (callouses on hands/feet, arterial insufficiency-thin, shiny on hairless part)
- -Edema
- -Turgor: How quickly skin snaps back when pinched
- -pinch skin on ant. chest below clavicle or forearm
- -poor turgor: tenting (skin doesn't snap back--sign of dehydration); don't test hands in elderly--false +
- -Hygeine: clean & free of odor
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*Objective data
-Vascularity
- -Cherry angiomas: tiny blood blister (bright red, papular lesion, 1-5mm; on trunk, upper chect, extremities; inc w/ age)
- -Telangiectases: dilated superficial BV
- -SPIDER ANGIOMA: central arterial (fiery red) w/ capillary radiations; blanches w/ pressure; on face, neck, arms, upper trunk--usually not below waist; assoc w/ liver dz (can't break down hormone) d/t dec metabolism of hormones resulting in estrogen excess
- -VENOUS STAR: bluish spider angioma; non blanching w/ pressure; primarily located on legs; assoc w/ varicose veins
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*Objective data
-Petechiae
- -1-3 mm, deep red, rounded
- -Results from superficial capillary bleeding
- -Caused by bacteremia (sepsis), bleeding disorders (thrombosytopenia--dec in platelets)
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*Objective data
-Purpura
- -Extensive confluent patch of petechiae
- -Reddish, purple, irregular (senile purpura r/t thinning skin)
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*Objective data
-Ecchymyosis
-Hematoma
-Pattern Injuries
- E-larger patch of capillary bleeding
- -r/t trauma, bleeding disorders or liver dysfunction
- -Purple/purple-blue fading to green, yellow, brown over time
- H: subcutaneous nodule (raised bruise)
- PI: suspect abuse (scalding, belt strap/buckle, cig burns)
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*Characteristics of Lesions
- -Color
- -Elevation: flat, raised, pedunculated (stalk--skin tag)
- -Configuration: shape or pattern
- -Size: metric--mm, cm
- -Number
- -Location (body part) & distribution (localized vs. generalized)
- -Discharge or exudate (color, odor)
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*Primary Lesions
-Flat Lesions
- -Macule: flat, circumscribed, discolored, <1cm (freckles, flat nevi, petechia)
- -Patch: flat, irregular, >1cm (vitiligo)
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*Primary Lesions
-Raised Lesions
- -Papule: solid, elevated, circumscribed, <1cm (raised nevus, wart-verruca)
- -Plaques: coalesced papules, >1cm (psoriasis); individual papules run together into larger mass
- -Nodule: solid, elevated, 1-2cm (lipoma = fatty growth)
- -Tumor: larger than a few cm, firm or soft (lipoma)
- -Wheal: superficial, raised, erythematous, irregular (allergic rxn, PPD, mosquito bite); causes interstitial edema
- -Urticaria: hives; wheels coalesce to form extensive rxn; intensely pruritic
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*Primary Lesions
-Fluid Filled (raised)
- -Vesicle: elevated cavity w/ clear fluid, <1cm (herpes simples, varicella, herpes zoster, contact dermatitis-poison ivy)
- -Bulla: elevated cavity w/ fluid, >1cm (blister, burns)
- -Pusutule: contains pus; filled w/ leukocytes, not necessarily infected (acne)
- -Cyst: encapsulated fluid filled cavity in dermis or sub-q (sebaceous cyst). If deep hard to ID if nodule or tumor (solid/raised, not fluid)
- -never cancerous
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*Secondary lesions (1-4)
- -Crust: thickened, dried exudate (dried serum/blood/pus) on top of 1° lesion (scab)
- -rupture of herpes vesicle--> crust w/ erythematous base
- -impetigo: staph & strep
- -Scale: compact flakes of skin (psoriasis-white, silvery), seborrheic dermatitis (yellow-greasy), seborrhea (dandruff)
- -Fissure: linear crack (cheilosis-corners of mouth), callused heels, tinea pedis (athletes foot b/t toes)
- -Erosion: shallow depression, moist, no bleeding (underneath vesicular ruptures--if chicken pox rupture)
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*Secondary Lesion (5-8)
- -Ulcer: deep depression into dermis; leaves scar (stasis ulcer, pressure sore)
- -Excoriation: superficial abrasion (dermatitis); inflamm of skin-red, open sore
- -Scar: CT replacing normal tissue. Atrophic-depressed scar (stretch marks-striae), hypertrophic-excess scar tissue 2° to inc collagen formation (keloid)
- -Lichenification: thickening of skin (eczema-atopic dermatitis), chronic sun exposure
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*Configurations of Lesions (1-5)
- -Annular: ring, clear center (tinea corporus-ring worm, pityriasis rosea)
- -Semiannular: 1/2 ring--moon shape
- -Discrete: isolated
- -Confluent: lesions run together (urticaria-appear as one)
- -Grouped: clusters of lesions (appear stuck together, individual lesions can still be identified)
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*Configurations of Lesions (6-10)
- -Gyrate: coiled spiral, snakelike
- -Iris: target appearance (has colored center unlike annular)
- -Linear: scratch
- -Web like/lace pattern: mottled appearance (hot bath for long time-skin gets blotchy
- -Zosteriform: linear along a nerve route (shingles-herpes zoster)
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