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37 Cards in this Set
- Front
- Back
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What are some functions of the skin? |
- protection - temperature regulation - prevention of penetration - vitamin D production - absorption and excretion - perception/sensation |
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What needs to be included in a nursing history for skin assessment? |
- history of skin disease - allergies - lesions - self-care behaviours - pigment changes - medications - excessive bruising - excessive dryness or moisture - changes in mole (size or color) |
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What is included in the physical assessment of skin? |
- color - temperature - turgor - lesions - texture - moisture - edema - vascularity - birthmarks - cleanliness - thickness |
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In terms of nails, what is assessed? |
- capillary refill time - shape - contour - nail bed colour - consistency |
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What are the purposes of ROM? |
- to assess mobility - to test for neuromuscular function - to assess injury - assess muscle tone |
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What are the 2 types of ROM exercises? |
- passive - active |
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What principles are included in the ROM exercises? |
- comfort - pain - mobility - body alignment - privacy - 5x/exercise |
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What interventions would help to maintain skin integrity? |
- proper nutrition - slider sheet - pillows |
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Abnormal findings of skin color |
- pallor - jaundice - erythema - cyanosis |
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erythema |
intense redness of skin from excess blood in dilated superficial capillaries |
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cyanosis |
bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood |
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pallor |
unhealthy pale appearance |
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Poor skin turgor is a sign of |
dehydration |
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Normal capillary refill time |
1 - 2 seconds |
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eczema |
medical condition in which patches of skin become rough and inflamed, with blisters that cause itching and bleeding |
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petechiae |
tiny punctate hemorrhages, 1-3 mm, round and discrete, and dark red, purple or brown |
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basal cell carcinoma |
-abnormal, uncontrolled growths or lesions that arise in the skin’s basal cells, which line the deepest layer of the epidermis usually starts as a skin coloured papule with translucent top rounded pearly borders develop with central red ulcer, looks like a large open pore with central yellowing |
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squamous cell carcinoma |
- common form of skin cancer that develops in the thin, flat squamous cells that make up the outer layer of the skin - scaly patch with sharp margins - central ulcer and surrounding erythema develop |
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hirsutism |
excess body hair in women that forms a male sexual pattern - caused by endocrine or metabolic dysfunction |
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alopecia |
- spot baldness, autoimmune disease in which hair is lost from some or all areas of the body |
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Developmental considerations for Older Adults during assessment of skin |
- skin loses elasticity; wrinkling and sagging results - atrophy of skin structures - subcutaneous fat + muscle tone lost - sweat glands decrease in number and function, resulting in dry skin |
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capillary refill time |
time taken for color to return to an external capillary bed after pressure is applied to cause blanching |
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How does a nurse assess for capillary refill time? |
depress the nail edge with firm pressure to cause blanching, and quick release |
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What is included in a nursing health history for musculoskeletal assessment? |
- pain, cramps - stiffness - swelling, heat, redness - limitation of movement - weakness - deformity - ADL's - trauma (fractures, sprains, dislocations) - self-care behaviours |
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What is assessed for joints, muscles, and extremities? |
- gait - height - posture - symmetry - alignment - muscle mass, muscle tone - ROM - any involuntary movements - signs of inflammation (redness, swelling, warmth, tenderness, loss of function) - gross deformities - |
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What are normal findings of the wrist, hands, and fingers? |
- wrist in slight extension in normal functional position - fingers lie straight in same axis as forearm - skin smooth - knuckle wrinkles present - joint surfaces are smooth - ROM includes: flexion, extension, hyperextension, abduction, adduction, radial flexion, ulnar flexion, opposition |
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What are normal findings for the feet and toes? |
- foot should align with long axis of lower leg - longitudinal arch - toes point straight forward, lie flat - ankles are smooth, bony prominences - skin smooth, even colouring - ROM includes: eversion, inversion, flexion ,extension, plantar flexion, dorsiflexion |
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edema |
fluid in the tissues causing swollen, tight, and shiny skin surfaces, most often from direct trauma or impaired venous return |
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pitting edema |
pitting edema occurs when pressure applied to the skin surface results in an indent in the skin |
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Functions of Musculoskeletal system |
- support to stand erect - movement - encase and protect inner organs - produce RBC in bone marrow - reservoir for storage of essential minerals |
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Developmental considerations for older adults during musculoskletal assessment |
- bone resportion (loss of bone) occurs - loss of bone density (osteoporosis) - decreased height - postural changes - distribution of subcutaneous fat changes, weight gain occurs - muscle decrease in size, loss in muscle mass occurs |
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macule |
freckle |
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papule |
small, raised, solid pimple or swelling - redness but no pus production |
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nodule/tumor |
wart |
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vesicle |
herpes/blister |
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pustule |
acne |
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wheal |
insect bite |
