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NSG 3160 Exam 2
Unit 3 Integumentary System
Macular Rashes: Soley a color change, flat and circumscribed <1cm in diameter
Ex: freckles, flat nevi, hypopigmentation, petechiae, mesles, scarlet fever
Pressure Ulcers
Stage 1 non blanchable erythema: intact skin is red but unbroken
Stage 2 partial thickness skin loss: loss of epidermis and exposed skin, looks
shallow like an abrasion or open blister with a red / pink wound bed
Stage 3 full thickness skin loss: extends into subcutaneous tissue but no
bone, muscle, or tendon is exposed
Stage 4 full thickness skin / tissue loss: all skin layers and extends into
supporting tissue exposing bone, muscle, or tendon may slough
Lichenification: prolonged intense scratching eventually thickens skin and produces
tightly packed sets of papules (looks like the surface of moss or lichen)
Pigmented mole: a mole that has color
Mole: clump of melanocytes, tan-brown in color, flat or raised, a mole has
symmetry, small size (<6mm), smooth borders, and single uniform
pigmentation
Erythematous plaques: Broad, raised, red areas on the skin caused by inflammation
or irritation typically >1cm, flat topped, and red in color
Hyperpigmented patches: large flat areas of the skin >1cm that are darker than the
surrounding akin because of excess of melanin
Medications that can cause sunlight sensitivity: sulfonamides, thiazide diuretics,
oral hypoglycemia agents, tetracycline
Antibiotics may cause allergic skin eruptions
Cherry (senial) angiomas: small 1-5 mm, smooth, slightly raised bright red dots that
commonly appear on the trunk in all adults older then 30 years old they normally
increase in size and number with aging but are not significant
Nail profiles
Normal: 160 degrees
Curved nail: 160 degrees or less
Early clubbing: 180 degrees
o Occurs with: congenital cyanotic heart disease, lung cancer, and
pulmonary diseases
o May have a spongy nail base
, 2
Normal skin findings
Color
o General pigmentation: even and consistent with genetic background
(dark skinned people normally have areas of lighter pigmentation on
the palms, nail beds, and lips). General pigmentation is darker in sun
exposed areas.
o Widespread color change: note any color change over the entire body.
Normally there is no change.
Temperature
o Palpate the skin it should be warm and temperature should be equal
bilaterally
o Hands and feet may be slightly cooler in a cool environment
Moisture
o Perspiration appears normally on the face, hands, axillae, and skin
folds in response to activity, a warm environment, or anxiety
o Look for dehydration in the oral mucous membranes normally there is
none and the mucous membranes look smooth and moist
o Dark skinned people may look dry and flaky but this does not
necessarily indicate systemic dehydration
Texture
o Normal skin feels smooth and firm with an even surface
Thickness
o The epidermis is uniformly thin over most of the body; although
thickened callus areas are normal on the palms and soles
Edema
o Edema is fluid accumulating in the interstitial space it is not normally
present
Mobility / turgor
o Pinch up a large fold of skin on the anterior chest under the clavicle
mobility is the ease of skin to rise and turgor is its ability to return to
place promptly when released
Equipment needed to perform a skin assessment
Strong direct lighting
Small centimeter ruler
Penlight
Gloves
For special procedures: woods light (filtered UV light), dermatoscope
Normal nail color
Translucent nail plate is a window to the even pink nail bed underneath
NSG 3160 Exam 2
Unit 3 Integumentary System
Macular Rashes: Soley a color change, flat and circumscribed <1cm in diameter
Ex: freckles, flat nevi, hypopigmentation, petechiae, mesles, scarlet fever
Pressure Ulcers
Stage 1 non blanchable erythema: intact skin is red but unbroken
Stage 2 partial thickness skin loss: loss of epidermis and exposed skin, looks
shallow like an abrasion or open blister with a red / pink wound bed
Stage 3 full thickness skin loss: extends into subcutaneous tissue but no
bone, muscle, or tendon is exposed
Stage 4 full thickness skin / tissue loss: all skin layers and extends into
supporting tissue exposing bone, muscle, or tendon may slough
Lichenification: prolonged intense scratching eventually thickens skin and produces
tightly packed sets of papules (looks like the surface of moss or lichen)
Pigmented mole: a mole that has color
Mole: clump of melanocytes, tan-brown in color, flat or raised, a mole has
symmetry, small size (<6mm), smooth borders, and single uniform
pigmentation
Erythematous plaques: Broad, raised, red areas on the skin caused by inflammation
or irritation typically >1cm, flat topped, and red in color
Hyperpigmented patches: large flat areas of the skin >1cm that are darker than the
surrounding akin because of excess of melanin
Medications that can cause sunlight sensitivity: sulfonamides, thiazide diuretics,
oral hypoglycemia agents, tetracycline
Antibiotics may cause allergic skin eruptions
Cherry (senial) angiomas: small 1-5 mm, smooth, slightly raised bright red dots that
commonly appear on the trunk in all adults older then 30 years old they normally
increase in size and number with aging but are not significant
Nail profiles
Normal: 160 degrees
Curved nail: 160 degrees or less
Early clubbing: 180 degrees
o Occurs with: congenital cyanotic heart disease, lung cancer, and
pulmonary diseases
o May have a spongy nail base
, 2
Normal skin findings
Color
o General pigmentation: even and consistent with genetic background
(dark skinned people normally have areas of lighter pigmentation on
the palms, nail beds, and lips). General pigmentation is darker in sun
exposed areas.
o Widespread color change: note any color change over the entire body.
Normally there is no change.
Temperature
o Palpate the skin it should be warm and temperature should be equal
bilaterally
o Hands and feet may be slightly cooler in a cool environment
Moisture
o Perspiration appears normally on the face, hands, axillae, and skin
folds in response to activity, a warm environment, or anxiety
o Look for dehydration in the oral mucous membranes normally there is
none and the mucous membranes look smooth and moist
o Dark skinned people may look dry and flaky but this does not
necessarily indicate systemic dehydration
Texture
o Normal skin feels smooth and firm with an even surface
Thickness
o The epidermis is uniformly thin over most of the body; although
thickened callus areas are normal on the palms and soles
Edema
o Edema is fluid accumulating in the interstitial space it is not normally
present
Mobility / turgor
o Pinch up a large fold of skin on the anterior chest under the clavicle
mobility is the ease of skin to rise and turgor is its ability to return to
place promptly when released
Equipment needed to perform a skin assessment
Strong direct lighting
Small centimeter ruler
Penlight
Gloves
For special procedures: woods light (filtered UV light), dermatoscope
Normal nail color
Translucent nail plate is a window to the even pink nail bed underneath
