NURS 6512 Midterm exam study Guide
NURS 6512 Midterm exam study Guide

Communication techniques used to obtain a patient’s health history (found in Seidel’s guide to physical examination, chapter 1, pages 1-7)

Ask the patient how the prefer to be addressed

b. Ask open-ended questions. Ensure to let the patient have time to discuss their concerns.

c. Be courteous- Knock before entering, ensure confidentiality, meet and acknowledge others that may be in the room and level of participation, respect modesty, allow patient to dress after examination before follow-up discussion

d. Ensure comfort- ensure physical comfort, have minimal furniture, maintain privacy, comfortable room temperature, good lighting, and do not overtire the patient NURS 6512 Midterm exam study Guide

e. Establish a connection- Maintain good eye contact (if cultural preferences allow), avoid professional jargon, actively listen, establish the patients history and conduct the physical exam before viewing previous studies and tests to avoid a predetermined path, be flexible, watch nonverbal cues, define concerns completely (where, severity, length, context, soothers/aggravators)

f. Establish confidentiality- Have patient summarize the discussion, allow more discussion if the patient has other concerns by asking “anything else you would like to bring up,” follow-up if there are questions you are unable to answer right away, if you make a mistake own up to it and make every effort to repair it

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g. Ensure appropriate dress and grooming paying attention to clean fingernails, modest clothing, and neat hair.

h. Seek certainty if patients responses to questions are unclear

i. Be direct and firm when discussing sensitive issues and document after the discussion is over
documentation

Medical record should be complete and legible

Each patient encounter should include

Reason for encounter (Chief Complaint)

Relevant history, PE findings, and test results

Assessment, clinical impressions, or diagnosis

Plan of care

Date and legible identity of the observer

Why test was ordered

Consulting physicians

Health risk

Patients progress
SOAP notes are a quick and efficient way to compile information and make decisions based on the information provided by the patient.

The information for SOAP notes can be found in the Sullivan Text

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

S-Subjective

O-Objective

A-Assessment

P-Plan

S-Chief Compliant (CC), history of present illness (HPI), Pertinent past medical history (PMH), Pertinent family history (FH), Pertinent psychosocial history (SH), any specialized history related to the chief complaint, and Pertinent review of systems (ROS) (Sullivan, pp.91-92).

O- Objective: includes the vital signs, a general assessment of the patient, physical examination findings, results from laboratory or diagnostic tests (Sullivan, p. 93)

A- Assessment: is an analysis and interpretation of the subjective and objective data to provide a diagnosis or a list of differential diagnoses (Sullivan, pp. 96-97).

P- Plan: this area includes diagnostic studies that will be obtained, referrals, therapeutic interventions, educational material, disposition of the patient, next visit (Sullivan, p. 99)

Subjective Data vs Objective Data (#4)

 
Information collection is a vital piece of any assessment process, regardless of whether it is for risk management, a health diagnosing, or an execution assessment. The emotional and target techniques for information accumulation are two conspicuous ones used to decide the kind of information gathered and the suspicions. While the previous is identified with verbal articulation of thought and the statements to take after, the last is identified with unquestionable and strong actuality.
 
Subjective Data
 

Subjective data or abstract information is information that is gathered or acquired through personal interactions, i.e., talking, sharing, clarifying, and so forth.
It is gathered to make an assumption about what the reality may be, what occasion may have happened, what estimations must be done, and so on.
Subjective information can likewise be gathered by methods for judgment, doubt, or rumors
This information fluctuates from one person to another, with each circumstance, consistently.
It can’t be announced as reality, as it advances from such a large number of changed sources with various information sources.
Abstract dialect as a rule starts with, ‘I think’, ‘I require’, ‘I feel’, and so on

 
Objective Data
 

By definition, objective data is information that is gathered or acquired by means of established or obvious realities and sources.
It is gathered to affirm your doubts and suppositions – or only to accumulate trustworthy data. It is something that can be felt, contacted, smelled, seen, heard, and tasted.
Objective information will be the same from numerous sources and can be checked and portrayed precisely and affirmed.
This information does not fluctuate from one person to another or with each circumstance.
It tends to be proclaimed as evident information since it stays same and reliable regardless of whether numerous sources are included.
Objective dialect more often than not starts with ‘I said’, ‘I watched’, ‘I gauged’, and so forth.

 
 
Subjective Data Vs. Objective Data
 
 

Underlying Basis

 Its underlying base is personal interpretation. Whatever is perceived is done so, upon communicating with the person about the same and believing what was said by the person/source.
 Its underlying base is observing what happened, observing the facts. The facts are straightforward or proved by means of a test/analysis/experiment, and are true and measurable.

Decision-making

 It cannot be completely relied on for taking decisions. After all, personal opinions and beliefs vary, and may present an entirely new perspective of the same problem. In such a scenario, a level-headed decision cannot be taken.
 It is based on facts; hence, it is usually reliable for decision-making. Whatever decision is taken is done so in the light of what has actually happened, that which can be trusted upon, with experiments and facts.

Common Arenas

 Subjective data and analysis can usually be found on personal blogs, forums, Internet chat stations, biographies, editorials, etc.
 Objective data is not a discussion. It is found in important scientific papers, encyclopedias, textbooks, reference books, tutorials, etc.

Reporting Information

 It cannot be used for reporting any news. As it is collected through discussions and interpretations, it is not totally reliable; therefore, making a definite assumption about an event or subject is incorrect.
 It can be used for reporting information. Data collection is done through efficient methods and reliable, set procedures. It is dependable and can be reported.

Examples

 When you have a cough and you go to the hospital, the doctor/nurse will ask you questions regarding your cough, like ‘When did it start?’, ‘Is it a dry cough or wet cough?’, ‘Did you eat/drink something cold?’, etc. The information obtained thus, is classified as subjective data.
 When you get a cough and go to the doctor, the doctor will examine you thoroughly, check your vital signs, conduct tests, and then, based on the test results, he will ascertain the problem you are suffering from (like bronchitis, pneumonia, etc.). This is objective data.

 
 

Ethical Decision Making and Beneficence

Four principles of medical ethics are autonomy, beneficence, non-maleficence, and justice. Beneficence is the principle of acting with the best interest of the other in mind, it is the basic premise that healthcare providers have a duty to be of a benefit to the patient as well as to take positive steps to prevent harm from the patient (Levitt, 2014). Ethics are moral principles that govern a person’s behavior. Ethical decision making is based on a person’s moral compass. Choosing to make the right decision is based on what a person believes is right.

 

Cultural Awareness (6)

*Cultural reflects the whole of human behavior including ideas and attitudes; ways of relating, speaking manners, products of physical effort, ingenuity and imagination.

*Cultural awareness- being knowledgeable of one’s thoughts, feelings, sensation and how these things affect interactions

Crossing the cultural divide helps, but skepticism is a barrier.

*Cultural humility- recognizing one’s limitation in knowledge and cultural perspective to be open to new perspectives; view each patient individually

*Seeleman et al framework- emphasizes on awareness of social context which specific ethnic groups live Social context in minority group means assessing stressors and support networks, sense of life control and literacy

*Campinha- Bacote’s process of Cultural Competence Model- includes (cultural competence dimensions): Awareness- self- examination and in -depth exploration of your biases, stereotypes, prejudices, and assumption

Knowledge- seeking and obtaining education

Skill- collecting culturally relevant data assessing in a cultural manner

Encounter- patient interactions used to validate, redefine or modify existing beliefs and practices and develop cultural desire or modify existing beliefs and practices and develop cultural desire awareness, skill, and knowledge

Desire- motivation to want engagement in being culturally competent

 

Socioeconomic, Spiritual and lifestyle factors affecting

diverse populations
Socioeconomic status is the social standing or class of an individual or group. It is often measured as a combination of education, income and occupation.

a. Diverse populations are often financially challenged, have educational limitations and have poor access to health care due to of lack of insurance or funding to pay for medication. The lack of health insurance reduces access to care and often results in poorer health outcomes (Bittoni et al, 2015). Healthcare providers must be sensitive to this factor and be knowledgeable about resources within the community to aid these populations to sustaining adequate healthcare (Ball et al, 2015 pg. 10).

b. Many patients want attention paid to spirituality and faith can be a key factor in the success of a management plan. When assessing spirituality continue to be sensitive and ask open ended questions such as:

i. What are your spiritual or religious beliefs?

ii. How do our religious beliefs affect your health care decisions (i.e. birth control)?

iii. Is there anyone from your faith that you would like to include in your healthcare needs (i.e. pastors, priest, or male family members)?

c. Lifestyle factors are the modifiable habits and ways of life that can greatly influence overall health and well-being. Many people of diverse populations have higher rates of engagement in factors that increase health risks such as smoking, poor diet, sedentariness, and poor sexual habits.

i. Assess dietary habits and make nutritional recommendations as needed.

ii. Encourage smoking and alcohol consumption modification or cessation.

iii. Encourage active lifestyle habits (vigorous exercise at least 30 min per day for cardiovascular health, and decreasing obesity)

iv. Assess the 5 Ps of sexual history

1. Partners, practices, protection, past history, and pregnancy prevention practices (Ball et al, 2015 pg. 12).

 

FUNCTIONAL ASSESSMENT

• Functional assessment is an attempt to understand your patient’s ability to achieve the basic ADL’s

• Should be made for all older adults and for any person who may be limited by disease or disability, acute OR chronic.

• Well-taken history and a meticulous physical exam can bring out subtle influences, such as tobacco and alcohol use, sedentary lifestyles, poor food selection, overuse of medications, and potentially emotional distress.

• Physical limitations such as cognitive ability or of the senses may be founded

• Keep in mind patients tend to overstate their abilities and obscure reality

When performing a functional assessment, consider a variety of disabilities: physical, cognitive, psychological, social, and sexual. It is just as important to understand a patient’s social and spiritual support system as it is their physical disabilities.

Disabilities include but are not limited to

Mobility

• Difficulty walking standard distances: ½ mile, 2-3 blocks, across a room, etc.

• Difficulty with stairs- climbing or descending

• Problems with balance

Upper Extremity function

• Difficulty grasping small objects or opening jars

• Difficulty reaching out or up overhead (reaching a shelf)

Housework

• Heavy (scrubbing floors, vacuuming)

• Light (dusting)

• meal preparation

• shopping

• medication use/set up

• money management

Instrumental ADL’s

• bathing, dressing, toileting, moving from bed to chair or from sitting to standing, eating, walking inside the home, etc.

**Any limitations, even is perceived as mild, will affect the patient’s independence and autonomy. This leads to increased reliance on other people and/or assistive devices.

** These limitations indicate the loss of physical reserve and the potential loss of physical function and independence that indicate the onset of frailty

** The patient’s support system and material resources become an integral part of development of reasonable management plans
 

Growth and Development Ch 6 of text book

Growth Hormone-Releasing Hormone stimulates the pituitary to release the growth hormone.
70% of secretion of the growth hormone occurs during sleep
Critical brain growth between conception and 3 yrs old.
Puberty- Dependent on the GH and androgens (Sex Steroids). They stimulate and increase in the growth Hormone.
Lymphatic tissues reach adult size by 6 yrs old and double by 10-12 yrs old.
 
Pregnancy Weight        
Child- 6-8lbs of wt       blood-3-4lbs      Maternal Fat/protein 4-6lbs
Uterus 2lbs                    breast 1-2 lbs
Fluid 2-3lb                       Amniotic fluid 2lbs
 
Older Adults
Physical Stature decrease at 50 yrs
60 yrs – decrease HT, WT, BMI
Increase Body Fat
 
Children and Adolescence
Sexual Maturation Girls
Early < 7 yrs  Delayed > 13 yrs
Sexual Maturation Boys
Early <9  Delayed > 14
 
BMI
Malnourished < 18 Normal 18.5-24.9 Overweight 25-29.9 Obese 30-39.9 Extreme >40
Measuring babies
Weight- Infants should be weight in Gm or KG to the nearest 10 gm
Normal newborn wt 2500-4000 gm * 5lbs 8oz – 8lbs 13 oz)
Lose 10 % of wt at birth and regain in 2 wks.
Birth weight doubles at 6 months and triples by 12 months
Head Circumference
Wrap measuring tape at occipital protuberance and supraorbital prominence.
Measure to the nearest 0.4cm
Place on the growth curve and compare with the standard.
Chest Circumference
Compare to head size
Wrap at nipple line
5 months – the head is  = or exceeds the chest size
5 months – 2yrs head = chest

2 yrs chest is > head.

Nutritional Assessment-

A nutritional assessment is the interpretation of data to determine whether and individuals in nourished or malnourished.

Measurements – length, height, weight, BMI

Recent weight gain or loss?

Allergies and intolerances
Food preferences (likes/ dislikes)
Type and amount of food and beverages

Home prepared? Fast food?

Frozen meals? Meat? Vegetable? Dairy? Sweats? Fish? Grain?
How often?

Water? Coffee? Tea? Juice? Soda? Milk? Alcohol?

How much and how often?

Any special diet?
Do you eat breakfast, lunch and dinner?
Physical activity- Low? Moderate? High? How many days per week? How many minutes?
How often do you have a bowel movement? Any use of laxatives? Gas? Diarrhea? Constipation? N/V?
Fluid Intake

Women 2.7 liters or 91 ounces or 11.5 cups of total water (from food and beverage)
Men 3.7 liters of 125 ounces or 11.5 cups of fluids daily.

Energy requirements:

Calculation is BMR X Activity Factor = Total daily energy expenditure

Macronutrients vs Micronutrients – Seidel p 95 & 96

• Macronutrients are carbohydrates, protein and fat and the main sources of calories in the diet.

o Carbohydrates are mostly from plants and in milk and is the main source of energy 4 calories /gram.

o Protiens provide 4 calories /gram and is present in all animal and plant products and is a part of more than half of the organic matter in the body.

o Fat provides 9 calories/gram and present in fatty fish, animal, and some plant products particularly seeds. Main source of linoleic acid.

• Micronutrients – vitamins, minerals, and electrolytes required and stored in very small quantities by the body. Essential for growth, development, and hundreds of metabolic processes.

 

Food Diary (pg. 101)

• A food diary can help to determine if a patient’s diet is adequate.

• It should be recorded in real time and include at least one weekend day.

• Practitioners should use a food diary to assess the eating habits and if a nutrition consult would be effective.

• The food diary can help the patient and practitioner to see trends and make suggestions in problem areas.

• A good resource to help can be found at ChooseMyPlate.gov

 

BMI measurements for normal, overweight, obesity, morbid obesity in adults and children

-undernutritionl = <18.5 -normal appropriate weight for height = 18.5 – 24.9 -Overweight = 25 – 29.9 -obese = 30 – 39.9 -Extremely obese = >40

 

PERNICIOUS ANEMIA

 

EXAMINATION TECHNIQUES AND EQUIPMENT

Tape measure – use to examine multiple raised lesions.
Transilluminate – An appropriate examination technique to assess vesicle in the skin. It also a source of light with a narrow beam.
Otoscope – use to visualize the lower and middle turbines of the nose.
Inspection – is applied throughout the entire examination and interview process.
Auscultation– is carried out  last except when examining kidney or abdomen . it is also used to listen for sounds produced by the body
Fist – use for indirect finger percussion involves striking  the middle finger of the nondominant hand
Deep abdominal palpation of the  kidney is used to assess tenderness over the kidney.
Ulnar surface of the hand is used to palpate Mass in the  skin
Diaphragm – pressed lightly against skin to detect high frequency.
Scoliometer- measures the degree of rotation of the spine to screen for scoliosis. Pg. 49  8th edition.
Pneumatic attachment of an otoscope – use to evaluate the cone of light reflex in adult and kids.
Red – free light -seen through the ophthalmoscope to estimate the size and location of lesion.
 
Dorsal surface of the hand – sensitive to vibration
Amsler grid– use to screen patient at risk for macular degeration
Pederson speculum– use for women with small vaginal opening
Near-vision (Rosenbaum) or Jaeger chart–  Use for screening near vision
Dermatoscope– is a skin surface microscope used to inspect the surface of pigmented skin lesions
Bell of stethoscope– detects low frequency sound.
Wood lamp-black light used to detect fungal infection.
Pan-optic ophthalmoscope– larger field of view in eye examination.
Palpation- gathering information through touch.
Monofilament– help identify a patient with decreased sensation and increased risk for injury
 
Percussion Tone Expected
 
Stomach- Tympanic
Sternum-flat
Liver-Dull
Lung with patient with Pneumonia-Dull
Abdomen with lung tumor-Dull
 

Assessment Tools

• Tuning Fork (p.45-46)- creates vibrations to produce frequencies of sound waves that can be expressed as cycles per second (cps) or Hertz (Hz).

o Auditory- Frequency of 500-1000 Hz is utilized. Activated by gently squeezing, or tapping on your knuckles.

o Vibration- use lower frequency between 100-400 Hz. Activated by tapping on heel of hand, and then applying the base to a bony prominence.

• Stethoscope (p. 39-40)- 3 basic types acoustic, magnetic, electronic with acoustic being most utilized.

o Acoustic- closed cylinder, the diaphragm has a frequency of 300 Hz, and is best for high pitched sounds such as the heart. The bell can pick up low frequency with light pressure, and high frequency with heavier pressure. (Stereophonic stethoscope has a dual channel with single tube, each ear piece picks up sound from its side of the bell.

o Magnetic- contains iron disk, and magnet. Contains dial to adjust from high to low frequency.

o Electronic- turns vibrations to sound, can record and store.

o Proper use- Hold between index and middle finger with firm pressure. To avoid unwanted noise, do not touch tubing during auscultation.

• Otoscope (p.45)- used for examining external auditory canal and tympanic membrane. Utilize the largest speculum that can fit comfortably in the patients ear.

• Ophthalmoscope (p.42-43)- Used to visualize interior eye structure. Some models offer a variety of apertures.

o Large Aperture produces large round beam, and is most often used.

o Small Aperture used for small pupils

o Red-free filter- produces green beam, and is used to evaluate the optic disc for pallor and small vessel changes. Can also detect retinal hemorrhages (blood appears as black),

o Visualizing

§ Eye structure is examined by converting or diverging light through different magnification powers.

§ Magnification power is selected by moving the lens selector. Black numbers represent positive, while red represents negative.The use of different lenses can assist in compensation of the patient and examiner with hyperopia and myopia. (No compensation for astigmatism is available)

 

Skin lesion characteristics

Skin lesion can describe any pathologic skin changes and can be primary or secondary.
Characteristics

• Size

• Shape

• Color

• Texture

• Elevation or depression

• Attachment at base: pedunculated (having a stalk) or sessile (without a stalk)

• Exudates

• Color

• Odor

• Amount

• Consistency

• Configuration

• Annular (rings)

• Grouped

• Linear

• Arciform (bow-shaped)

• Diffuse

• Location and distribution

• Generalized or localized

• Region of the body

• Patterns

• Discrete or confluent
 

Documenting Skin Lesions using the ABCD Rule

Skin lesions are evaluated based on the ABCDE rule (Melanoma Research Foundation)
A=Asymmetry- i.e. irregular shape
B=Borders- not easy to define the margins of the border
C=Color- presence of multiple colors may be a sign of malignancy
D=Diameter- >6 mm can be a sign of malignancy (size of pencil eraser)
E=Evolution- changes over time
Pay attention to location of lesions- Box 8-6, (Seidel, p. 132)
Pay attention to any exudate- Box 8-5, (Seidel, p. 125)
Table 8-4 Primary Skin lesions (Seidel, p. 126-128)
Table 8-5 Secondary Skin lesions (Seidel, p. 129-131)

Anatomy and Physiology of Skin Layers

Skin functions:

Protect against microbial and foreign substance invasion and physical trauma
Restrict body fluid loss
Regulate temperature
Sensory perception via nerve endings
Produce Vitamin D from precursors in skin
Contribute to blood pressure regulation through constriction
Repair surface wounds
Excrete sweat, urea, and lactic acid

 
Epidermis

Outermost portion of skin
Two layers

Stratum Corneum : Protects body against harmful environmental substances and restricts water loss

Contains dead squamous cells that form a protective barrier

Cellular stratum: keratin cells are synthesized here

Contains stratum germinativum – keratinocytes matures here- then make way through stratum spinosum, stratum granulosum, into stratum corneum
Stratum germinativum contains melanocytes which synthesize melanin and give skin color
Stratum lucidum is only in thicker skin of palms and soles

Avascular- depends on dermis for nutrition

Dermis

Richly vascular connective tissue layer that supports and separates the epidermis from the cutaneous adipose tissue
Papillae from this layer penetrate the epidermis to provide nourishment
Elastin collagen and reticulum fibers are found here and provide resilience, strength, and stability
Sensory nerve fibers are located here to provide sensation of pain, touch, and temperature
Additionally, found are autonomic motor nerves that innervate blood vessels, glands, and the arrectores pullorum muscles

Hypodermis:

A subcutaneous layer that is loose connective tissue filled with fatty cells
This adipose layer generates heat and provides insulation, shock absorption, and a reserve of calories

Appendages:

Eccrine sweat glands

Open onto the surface of the skin and regulate body temperature through water secretion
Everywhere except lip, eardrum, nail beds, inner surface of prepuce, and glans penis

Apocrine sweat glands

Only found in the axillae, nipples, areolae, anogenital areas, eyelids, and external ears
Emotional stimuli= these glands secrete a white fluid containing protein, carbs, and other substances; odorless; body odor is due to bacterial decomposition of apocrine glands

Sebaceous glands

Secrete sebum that keeps the skin and hair from drying out
Secretory activity varies according to hormonal levels throughout the life span

Hair

Consists of root, shaft, and follicle

Papilla at the base of the follicle supplies nourishment for growth
Melanocytes in shaft provide color

Vellus hair: short, fine, soft, and nonpigmented
Terminal hair: coarser, longer, thicker, and pigmented

Three stages of hair

Anagen (growth)
Catagen (atrophy)
Telogen (Rest)

Nails

Epidermal cells converted to hard plates of keratin
Vascular nail bed gives nail its pink color
Stratum corneum layer of skin covering the nail root is the cuticle or eponychium, which pushes up and over the lower part of the nail body
Paronychium : soft tissue surrounding the nail border

ALL ABOVE INFORMATION FOUND IN SEIDEL’S GUIDE TO PHYSICAL EXAMINATION: EIGTH EDITION PAGES 114-116
 
 

Abnormal nail findings in older adults

Nail changes associated with aging are common in the elderly and include characteristic modifications of color, contour, growth, surface, thickness, and histology. The calcium content of the aging nail increases and iron decreases.

keratinocytes of the nail plate are increased in size with an increased number of ‘pertinax bodies’ (remnants of keratinocyte nuclei)

• nail bed dermis also shows thickening of the blood vessels and elastic tissue, especially beneath the pink part of the nail.

• Nail growth decreases by approximately 0.5% per year between 20 and 100 years of age.

• Prominent longitudinal ridges were the most common change

• Brittleness of the nail is a common condition related to aging.

• Onychauxis which is an age-associated thickening of the nail plate

• changes in nail contour, increased transverse curvature

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2965930/

White banding (Terry Nails) is a nail disorder that is specifically linked to age – p. 158.

Pathophysiology: associated with cirrhosis, CHF, adult-onset diabetes mellitus, and age.

Appearance: transverse white bands cover the nail except for narrow zone at the distal tip
Onychomycosis is a fungal infection that causes the nail plate to crumble – p. 156.

Pathophysiology: this is not specifically related to older adults but is associated with loss of manual dexterity (interfere with exercise or walking).

Appearance: distal nail plate turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed
 

PSORIATIC SKIN LESIONS

Psoriasis is a common skin condition that speeds up the life cycle of skin cells. It causes cells to build up rapidly on the surface of the skin. The extra skin cells form scales and red patches that are itchy and sometimes painful.

Psoriasis is a chronic disease that often comes and goes. The main goal of treatment is to stop the skin cells from growing so quickly.

There is no cure for psoriasis, but you can manage symptoms. Lifestyle measures, such as moisturizing, quitting smoking and managing stress, may help
here are several types of psoriasis. These include:

• Plaque psoriasis. The most common form, plaque psoriasis causes dry, raised, red skin lesions (plaques) covered with silvery scales. The plaques might be itchy or painful and there may be few or many. They can occur anywhere on your body, including your genitals and the soft tissue inside your mouth.

• Nail psoriasis. Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Severe cases may cause the nail to crumble.

• Guttate psoriasis. This type primarily affects young adults and children. It’s usually triggered by a bacterial infection such as strep throat. It’s marked by small, water-drop-shaped, scaling lesions on your trunk, arms, legs and scalp.

The lesions are covered by a fine scale and aren’t as thick as typical plaques are. You may have a single outbreak that goes away on its own, or you may have repeated episodes.

• Inverse psoriasis. This mainly affects the skin in the armpits, in the groin, under the breasts and around the genitals. Inverse psoriasis causes smooth patches of red, inflamed skin that worsen with friction and sweating. Fungal infections may trigger this type of psoriasis.

• Pustular psoriasis. This uncommon form of psoriasis can occur in widespread patches (generalized pustular psoriasis) or in smaller areas on your hands, feet or fingertips.

It generally develops quickly, with pus-filled blisters appearing just hours after your skin becomes red and tender. The blisters may come and go frequently. Generalized pustular psoriasis can also cause fever, chills, severe itching and diarrhea.

• Erythrodermic psoriasis. The least common type of psoriasis, erythrodermic psoriasis can cover your entire body with a red, peeling rash that can itch or burn intensely.

• Psoriatic arthritis. In addition to inflamed, scaly skin, psoriatic arthritis causes swollen, painful joints that are typical of arthritis. Sometimes the joint symptoms are the first or only manifestation of psoriasis or at times only nail changes are seen. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. Although the disease usually isn’t as crippling as other forms of arthritis, it can cause stiffness and progressive joint damage that in the most serious cases may lead to permanent deformity.

Causes

The cause of psoriasis isn’t fully understood, but it’s thought to be related to an immune system problem with T cells and other white blood cells, called neutrophils, in your body.

T cells normally travel through the body to defend against foreign substances, such as viruses or bacteria.

But if you have psoriasis, the T cells attack healthy skin cells by mistake, as if to heal a wound or to fight an infection.

Overactive T cells also trigger increased production of healthy skin cells, more T cells and other white blood cells, especially neutrophils. These travel into the skin causing redness and sometimes pus in pustular lesions. Dilated blood vessels in psoriasis-affected areas create warmth and redness in the skin lesions.

The process becomes an ongoing cycle in which new skin cells move to the outermost layer of skin too quickly — in days rather than weeks. Skin cells build up in thick, scaly patches on the skin’s surface, continuing until treatment stops the cycle.

Just what causes T cells to malfunction in people with psoriasis isn’t entirely clear. Researchers believe both genetics and environmental factors play a role.

Psoriasis triggers

Psoriasis typically starts or worsens because of a trigger that you may be able to identify and avoid. Factors that may trigger psoriasis include:

• Infections, such as strep throat or skin infections

• Injury to the skin, such as a cut or scrape, a bug bite, or a severe sunburn

• Stress

• Smoking

• Heavy alcohol consumption

• Vitamin D deficiency

• Certain medications — including lithium, which is prescribed for bipolar disorder, high blood pressure medications such as beta blockers, antimalarial drugs, and iodides

Risk factors

Anyone can develop psoriasis, but these factors can increase your risk of developing the disease:

• Family history. This is one of the most significant risk factors. Having one parent with psoriasis increases your risk of getting the disease, and having two parents with psoriasis increases your risk even more.

• Viral and bacterial infections. People with HIV are more likely to develop psoriasis than people with healthy immune systems are. Children and young adults with recurring infections, particularly strep throat, also may be at increased risk.

• Stress. Because stress can impact your immune system, high stress levels may increase your risk of psoriasis.

• Obesity. Excess weight increases the risk of psoriasis. Lesions

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