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33 Cards in this Set

  • Front
  • Back
what are the roles of skin
-protection
-thermoregualtion
-innate immunity
-sensory function
what consists of the skin assessment
-pigment should be consistent
-temperature
-turgor
-moisture
-texture
-determine cause to why skin changed its appearance
what are possible causes for skin to look:
Pallor
-pain
-edema
-anxiety
-not feeling well
-rhenoids
what are possible causes for skin to look:
cyanosis
-decreased O2
-cold
what are possible causes for skin to look:
erythema
-fever
-sunburn
-inflammation
-CO2 posioning
what are possible causes for skin to look:
jaundice
-liver dysfunction
what are possible causes for skin to look:
vitiligo
-born with or can develop with age.
-is a variation in skin tone
what are possible causes for skin to look:
bruising
-abuse
-clotting issues
-nutrition deficient
-heparin
how do you establish a baseline when looking at skin
-look at soles of feet, palms of hands
-use natural daylight if possible
What are the components for "temperature"
-heat
-cold
-moisture/dryness (lips, eyes)
-diaphoresis (accompanied by chest pain?)
-clamminess
what do you need to check for in regards to lesions
-type
-size/depth
-granulation status
-presence of scar tissue
-dressing
-drainage
-ABCs
what are the ABCs of skin
-asymmetry
-border irregularity
-color
-diameter (6mm)
-evolution
-elevation
-surface
what color may moles appear
black, blue, white, modeled
if an incision is XXXX what type of surgery may they have had:
R upper quadrant
gall bladder
if an incision is XXXX what type of surgery may they have had:
Right lower quadrant
appendictumy
if an incision is XXXX what type of surgery may they have had:
medial inguinal line
c-section
hysterctomy
if an incision is XXXX what type of surgery may they have had:
L lower quadrant, below inguinal ligament
hernia
if an incision is XXXX what type of surgery may they have had:
R of umbilicus
liver biopsy
standard incision
if an incision is XXXX what type of surgery may they have had:
linea alba and to left of umbilibus
liver biopsy
standard incision
if an incision is XXXX what type of surgery may they have had:
left upper quadrant under ribs
kidney
what words can be used to describe the texture of skin
-rough
-scaly
-dry
-thick
-smooth
-oily
-thin
what is cradle cap
overproduction of oils
Describe normal turgor
rises easily and also returns to normal position, snaps backs
describe abnormal turgor
tents and doesn't assume normal position
where do you check of turgor in most people, and in elderly
in most people check near clavicle or forearm
for elderly check at sternum
what consists of special assessments for skin
-pressure ulcers
-nail beds
-lymph nodes
what is stage 1 of pressure ulcer
skin changes observable (temperature)
what is stage 2 of pressure ulcer
epidermis and dermis layers are damaged, ulcer is superficial and presents as an abrasion, blister or shallow crater
what is stage 3 of pressure ulcer
damage through to subcutaneous tissues, does not extend through fascia, appears as a deep crater
what is stage 4 of pressure ulcer
involvement of muscle,bone, tendon, joint capsule, or other supporting, structures
what are some follow up questions when assessing skin and seeing something questionable
-how long have you had this
-has it changed
-has your doctor seen it
-itch, pain, sore, burning
-anyone else in the house have this
-any new medications
-any recent travel, exposure
-anywhere else on your body
-trouble breathing/swallowing
-any other sxs of any other type anywhere on body
Skin lesions can be:
-hereditary
-systemic
-associated with inflammation/injury
what systemic conditions can be associated with skin lesions
-paraneoplastic syndromes
-endocrine systemic disorders
-vascular insufficiency
-metabolic disorders