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41 Cards in this Set
- Front
- Back
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Basic assessments include: |
color, temperature, moisture, turgor, odor, edema
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Erythema
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localized vasodilation. Redness. Can be IV site, rash.
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Diaphoresis
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sweating
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turgor
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Hydration of patient. Pinch skin. Tenting (stays up): dehydration.
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Decreased skin turgor is associated with increased risk of:
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skin breakdown.
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macule
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flat. change in skin color. <1cm. nonpalpable. Examples: freckle, petechiae.
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Papule
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palpable, circumscribed, solid elevation in skin. <1cm.
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Vesicle
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circumscribed elevation of skin. Filled with serous fluid. <1cm. Example: herpes simplex, chickenpox.
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Pustule
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circumscribed elevation of skin similar to vesicle. Filled with pus. Varies in size. Example: acne, staph infection.
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Keloid
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growth of extra scar tissue.
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Petechiae
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nonblanching. pinpoint size. red or purple spots. Cause by small hemorrhages in skin layers.
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Hematoma
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localized collection of blood underneath the tissues. Appears as swelling, change in color, sensation, warmth or mass. Ofen bluish discoloration.
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Cyanosis
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bluish discoloration. Lips, nail beds, palpebral conjunctivae, palms.
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Jaundice
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yellow-orange discoloration. Sclera.
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Senile kerastosis
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thickening of skin.
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Ecchymosis
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discoloratin of the skin or bruising. caused by blood leakage into subcutaneous tissues. Result of trauma to underlying tissues.
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People at risk for skin breakdown
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neurologically impaired, chronically ill, decreased mental status, poor tissue oxygenation, decreased cardiac output, inadequate nutrition
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Braden scale categories
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sensory perception, moisture, activity, mobility, nutrition, friction & shear.
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Braden scale scoring
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Ranges from 6-23. The lower the number, the higher the risk.
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Stage 1 pressure ulcer
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Nonblanchable. Redness. Intact skin. May be present: warmth, edema, pain, hardness, discoloration.
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Stage 2 pressure ulcer
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partial thickness skin loss or blister. shallow open ulcer. Red-pink. May be: intact or serum filled; shiny or dry ulcer w/o slough or bruising.
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Stage 3 pressure ulcer
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full thickness skin loss (fat visible). Bone, tendon, muscle NOT exposed. Some slough may be present. May include undermining.
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Stage 4 pressure ulcer
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full thickness tissue loss (muscle/bone visible). Slough or eschar (dead tissue) may be present. May include undermining.
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Unstageable/unclassified pressure ulcer
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full thickness skin or tissue loss. Depth unknown. Depth completely obscured by slough or eschar. Either a stage 3 or 4.
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Suspected deep tisue injury
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depth unknown. Purple or maroon. Localized. Intact or blood filled blister.
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3 key things to assess on lesions
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1. appearance: color, location, texture, size, shape, type, groupingg, distribution. 2. exudate: odor, amount, consistency. 3. Dimensions: height, width, depth
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Basal cell carcinoma
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related to sun exposure. almost never spreads. 0.5-1cm flat or raised area.
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Squamous cell cancer
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may travel to lymph nodes or elsewhere. 0.5-1.5cm. Sometimes ulcerated or crusted.
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Malignant melanoma
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develops from melanocytes (produces skin pigment melanin). Begins as mole or other area that has changed in appearance.
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Basic rules for assessing any carcinoma
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Asymmetry: look for uneven shape. Border irregularity: look for blurred, notched, ragged edges. Color: look for pigmentation that is not uniform. Diameter: look for areas greater than the standard pencil eraser.
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Malignancy (lesions)
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indistinct margins, different pigments, irregular borders, changing.
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Skin changes with aging
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wrinkled and leathery due to decreased collagen, subcutaneous fat, sweat glands. Dry skin.
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Hair changes with aging
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dry, brittle hair. Dull gray, white, or yellow. hair may thin over scalpe, axillae, pubic areas.
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Nail changes with aging
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brittle, dull, opaque, yellow. Harder, thicker.
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Alopecia
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hair loss or thinning. (usually due to genetics or endocrine disorders)
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Nail clubbing
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angle of nail and nail base is greater than 180 degrees. Due to chronic lack of oxygen; heart or pulmonary disease.
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Pediculus human capitis
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head lice. placed in isolation. full ppe. Does not necessarily reflect the person's personal hygiene.
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Hirsutism
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women mmay grow hair on upper lip, chin, cheeks and vellus (hair that covers body) hair becomes coarse.
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Reduced body hair coverage
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may be due to aging or result of arterial insufficiency.
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Excessively oil hair is related to:
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androgen hormone stimulation.
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Paronychia |
inflammation of skin at base of nail. Causes: local infection, trauma. |
