Health Assessment Key Terms

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Abuse Assessment Screen (AAS)

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Abuse Assessment Screen (AAS) -
The AAS has strong support for reliability and validity. Many health care professioanls precede the questions with an introduction such as " Because domestic violence is so common in our society, we are asking all women the following questions". This lets them know that they are not being singled out for the questions. If a women answers yes to any of the AAS questions, you need to ask questions to assess how recent and how serious the abuse was. This type of assessment is like "peeling layers of an onion," with more violence being uncovered as the assessment continues. This is not denial on the women's part but rather the normal minimiazation that often accompanies thauma from violence.
Concern and distress about the level of violence (from the health care provider) is appropriate. One message that needs to be conveyed during the assessment is that it is not the woman's fault. Another important message is that you are concerned and help is possible. It is important to remember that abuse is not always directed at women, you may come across a male that has been abused. The AAs is also used for child abuse and elderly abuse screening.

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child emotional abuse

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any pattern of behavior that harms a child's emotional developmetn or sense of self-worth. It includes frequent belittling, rejection, threats, and withholding of love and support.

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child neglect

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failure to provide for a child's basic needs (physical, educational, emotional, or medical).

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child physical abuse

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physical injury due to punching, beating, kicking, biting, burning, shaking, or otherwise harming a child. Even if the caretaker did not intend to harm the child, such acts are considered abuse when done purposely.

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child sexual abuse

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includes fondeling a child's genitals, incest, penetration, rape, sodomy, indecent exposure, and commercial explotation through prostitution or the production of pornographis material

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child psychological abuse

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infliction of emotional/mental anguish by humiliation, coercion, and threats and/or lack of social stimulation. Examples: yelling threats of harm, withholding basic medical and/or personal care, and leaving the alone for long periods of time

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physical elder abuse

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violent acts that result or could result in injury, willful infliction of force that results in bodily harm, pain and/or impairment on a person age 65 or older.

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physical elder neglect

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physical harm to a person 65 or older because of failure to provide for the person's well-being. Examples: inadequate feeding and hydration, unsanitary living conditions, and poor person hygeine, adequate shelter, and withholding medications

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psychological elder neglect

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failing to provide basic social stimulation

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psychological elder abuse

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behaviors that result in mental anguish; infliction of emotional/mental anguish by humiliation, coercion, and threats and/or lack of social stimulation. Examples: yelling threats of harm, withholding basic medical and/or personal care, and leaving the alone for long periods of time

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Elder Financial Abuse

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intentional misuse of an elderly person's finacial or material resources without the informed consent of the person

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Elder Financial Neglect

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failure to use the assets of the elderly person to provide services needed by the elderly person
Intimate partner violence (IPV)-

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Intimate Partner Violence (IPV)

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physical and/or sexual violence (use of physical force) or threat of such violence
psychological/emotional abuse and/or coercive tactics when there has been prior physical and/or sexual violence between spouses or nonmarital partners or former spouces or nonmarital partners

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Routine, Universal screening for IPV

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asking all adult patients whether they have experienced IPV each time they are in the health care system no matter what their complaint

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Mandatory Reporting of Abuse

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a specified group of people (health care providers) is required by law to report abuse to a governmetal agency

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Sexual Abuse

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either child sexual abuse or forced sexual acts of an adult on another adult or the elderlyPhysical elder abuse-
violent acts that result or could result in injury, willful infliction of force that results in bodily harm, pain and/or impairment on a person age 65 or older.

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Abrasion

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A wound caused by rubbing the skin or mucous membrane

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Avulsion

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The tearing away of a structure or part

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Bruise

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Superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface, without the skin itself being broken; also called a contusion

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Contrusion

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A bruise; injury to tissues without breakage of skin; blood from broken blood vessels accumulates, producing pain, swelling, tenderness

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Cut: Incision

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A cut or wound made by a sharp instrument; the act of cutting

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Ecchymosis

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A hemorrhagic spot or blotch, larger than petechia, in the skin or mucous membrane, forming a nonelevated, rounded or regular, blue or purplish patch

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Hematoma

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: A localized collection of extravasated blood, usually clotted in an organ, space, or tissue

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Hemorrhage

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The escape of blood from a ruptured vessel, which can be external, internal, and/or into the skin or other organ

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Laceration

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The act of tearing or splitting; a wound produced by the tearing and/or splitting of body tissue, usually from blunt impact over a bony surface

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Lesion

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A broad term referring to any pathologic or traumatic discontinuity of tissue or loss of function of a part

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Patterned Injury

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An injury caused by an object that leaves a distinct pattern on the skin and/or organ (being whipped with an extension cord) or an injury caused by a unique mechanism of injury (immersion burns to the hands [glove burns] or feet [sock burns])

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Pattern of Injuries

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Injuries, usually bruises and fractures, in various stages of healing

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Petechiae

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Minute, pinpoint, nonraised, perfectly round, purplish red spots caused by intradermal or submucous hemorrhage, which later turn blue or yellow (thrombocytopenia, subacute bacterial endocarditis, and other septicemias are characterized by petechiae in mucous membranes and skin)

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Puncture

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The act of piercing or penetrating with a pointed object or instrument

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stab wound

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: A penetrating, sharp, cutting injury that is deeper than it is wide

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traumatic alopecia

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Loss of hair from pulling and yanking or by other traumatic means

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wound

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General term referring to a bodily injury caused by physical means

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freckles

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Small, flat macules of brown melanin pigment that occur on sun-exposed skin

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birthmarks

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: may be tan to brown in color

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anemia

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Decreased hematocrit

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shock

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decreased perfusion, vasoconstriction

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annular

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circular, begins in center and spreads to periphery (tinea corporis/ringworm, tinea versicolor, pityriasis rosea)

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confluent

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lesions run together (urticaria [Hives])

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discrete

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Distinct, individual lesions that remain separate (molluscum)

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Grouped

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: Clusters of lesions (vesicles of contact dermatitis)

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Gyrate

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Twisted, coiled, spiral, snakelike

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Target

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Iris, resembles iris of eye, concentric rings of color in the lesions (erythema multiforme)

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Linear

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A scratch, streak, line, or stripe

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Polycyclic

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Annular lesions grow together (Lichen planus, psoriasis)

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Zosteriform

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Linear arrangement along a nerve route (Herpes zoster)

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Macule

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Solely a color change, flat, circumscribed, of less than 1 cm (freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever)

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Papule

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Something you can feel (solid, elevated, circumscribed, less than 1cm diameter) caused by superficial thickening in the epidermis (mole, lichen planus, molluscum, wart (verruca))

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Patch

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Macules that are larger than 1cm (Mongolian spot, vitiligo, café au lait spot, chloasma, measles rash)

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Plaque

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skin lesion in which papules coalesce or come together, wider than 1cm, disk-shaped (psoriasis, lichen, planus)

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Nodule

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Elevated skin lesion, greater than 1cm diameter (xanthoma, fibroma, intradermal nevi)

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Wheal

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: raised red skin lesion due to interstitial fluid (mosquito bites, allergic reaction, dermographism)

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Tumor

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larger than a few cm, firm or soft, deeper into dermis, may be benign or malignant

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Urticaria (Hives)

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Wheals coalesce to form extensive reaction, intensely pruritic

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Vesicle

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elevated cavity containing free fluid up to 1cm diameter (herpes simplex, varicella, herpes zoster, contact dermatitis)

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Actinic (senile or solar) Keratosis

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these lesions are red-tan scaly plagues that increase over the years to become raised and roughened.

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Keratoses

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are lesions that are raised, thickened areas of pigmentation that look crusted, scaly, and warty.

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Alopecia

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baldness, hair loss

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Cyanosis

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dusky blue color to skin or mucous membranes due to increased amount of unoxygenated hemoglobin

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Diaphoresis

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profuse perspiration, accumpanies an increase metabolic rate, such as occurs in heavy activity or fever

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Ecchymosis

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superifcial bleeding under teh skin or a mucous membrane; a bruise

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Edema

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body tissues contain an excessive amount of tissue fluid in the interstitial spaces.

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Ascites

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is the term for third spacing fluid excess

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Ephelides

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freckles

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Erythema

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intense redness of the skin due to excess blood in dialated superficial capallaires, as in fever or inflammation

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Hematoma

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a bruise you can feel, it elevates the skin and is seen as swelling

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Hirsutism

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condition characterized by the excessive growth of hair or the presence of hair in unusual places in females forming a male sexual pattern; caused by endocrine or metabolic dysfunction or occasionally idiopathic

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Jaundice

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yellow color to skin, palate, and sclera due to excess bilirubin in the blood

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Keloid

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hypertrophic scar, elevated beyond site of original injury

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Lesion

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a circumscribed area of pathologically altered tissue, a single infected patch in a skin disease; a broad term refering to any pathogenic or traumatic discontinuity of tissue or loss of function of that part

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Macule

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flat skin lesion with only a color change Examples: freckales, flat nevi, hypopigmentation, petechiae, measles, scarlet fever

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melanoma

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a malignant tumor of darky pigmented cells (melanocytes) that often arises in a brown or black mole. They can spreas aggresively through the body

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nevus (mole)

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) circumscribed skin lesion due to excess melanocytes

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pallor

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excessively pale, whitish-pink color to lightly pigmented skin

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pruritus

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itching

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striae- stria

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- a line or band elevated above or depressed below surrounding tissue, or differening in color and texture. A streak!

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turgor

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- normal tension in a cell

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skin turgor

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- the resistance of the skin to deformation. In a healthy person, when the skin on the back of tehhand is grasped between the fingers and released, it returns to its normal appearnance either immediatley or relatively slowly. The state of hydration of the skin can determine which of these reactions occurs, but age is the most important factor. Increase in age = slower return to normal position

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xerosis

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abnormal dryness of the skin, mucous membranes, or conjunctiva

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bulla

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elevated cavity containing free fluid larger than 1cm diameter (friction blister, pemphigus, burns)

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cyst

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Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin (sebaceous cyst)

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pustule

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elevated cavity containing thick turbid fluid/pus (acne)

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scale

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: Compact desiccated flakes of skin from shedding of dead skin cells (eczema, ichthyosis, dry skin)

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crust

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thick, dried-out exudates left on skin when vesicles/pustules burst or dry up, color can be red-brown or honey or yellow

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fissure

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linear crack in skin extending into dermis (cheilosis at the corners of mouth due to excess moisture, athlete’s foot)

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erosion

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scooped out, shallow depression in skin, moist but no bleeding, heals without scar bc erosion does not extend into dermis

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ulcer

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Sloughing of necrotic inflammatory tissue that causes a deep depression in skin, extending into dermis (stasis ulcer, pressure sore, chancre)

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excoriation

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self-inflicted abrasion on skin due to scratching (insect bites, scabies dermatitis, varicella)

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scar

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: After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change

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atrophic scar

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Resulting skin level depressed with loss of tissue, thinning of the epidermis (striae)

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lichenification

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tightly packed set of papules that thickens skin, from prolonged intense scratching, looks like surface moss

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keloid

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Hypertrophic scar, elevated beyond site of original injury

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hemangiomas

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skin lesion due to benign proliferation of blood vessels in the dermis (Port-wine stain, Strawberry Mark, Cavernous Hemangioma)

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port-wine stain

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(Nevus Flammeus): a large, flat macular patch covering the scalp or face, frequently along the distribution of the cranial nerve V, color- dark red, bluish, or purplish, marking consists of mature capillaries, present at birth, usually doesn’t fade

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strawberry mark

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(Immature Hemangioma): A raised, bright red area with well defined borders, 2-3cm in diameter, does not blanch with pressure, immature capillaries, present at birth and disappears by 5-7yr

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cavernous hemangioma

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): Reddish-blue, irregularly shaped, solid and spongy mass of blood vessels

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telangiectases

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skin lesion due to permanently enlarged and dilated blood vessels that are visible on skin surface (Spider or Star Angioma, Venous Lake)

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spider or star angioma

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A fiery red, star-shapped marking with solid circular center, capillary radiations extend from the central arterial body, develops on face, neck, or chest, associated with pregnancy, chronic liver disease, or estrogen therapy

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venous lake

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Blue-purple dilation of venules and capillaries in a stare-shaped, linear, or flaring pattern, on legs near varicose veins and face, lips, ears, and chest

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purpuric lesions

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red-purple skin lesion due to blood in tissues from breaks in blood vessels, red blood cells and blood pigments are deposited in the tissues (Petechiae, Purpura)

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purpura

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red-purple skin lesion due to blood in tissues from breaks in blood vessels, confluent and extensive patch of petechiae and ecchymoses, >3mm flat, macular hemorrhage (seen in thrombocytopenia and scurvy, old age)

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common skin lesions in children

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Diaper dermatitis, intertrigo (candidiasis), Impetigo, Atopic Dermatitis (Eczema), Measles (Rubeola), German Measles (Rubella), Chickenpox (Varicella)