Assessment Techniques & Skin

Question 1

What are some components of the health assessment?

Answer 1

Health history and the physical exam

Question 2

What is a health history

Answer 2

subjective data (what the patient says)

Question 3

what is a physical exam

Answer 3

objective data and Head to toe

Question 4

Comprehensive assessment

Answer 4

look at every part of the person

Question 5

ongoing-partial (follow up) assessment

Answer 5

how they are doing at that point in time

Question 6

focused assessment

Answer 6

zoom in on what the patient is complaining of

Question 7

emergency assessment

Answer 7

airway breathing and circulation

Question 8

Assessment techniques

Answer 8

inspect, palpate, auscultate, percuss

Question 9

Which layer of the skin sore adipose tissue for energy

Answer 9

hypodermis

Question 10

what is one function of the skin

Answer 10

resist invasion of microorganisms

Question 11

What are you looking for when you inspect the skin?

Answer 11

color, vascularity, integrity/continuity, lesions/rashes

Question 12

What are you palpating when you palpate the skin?

Answer 12

temperature, moisture, texture, tugor, edema (0-4 scale)

Question 13

1+ pitting edema

Answer 13

slight indentation, normal contours, fluid volume 30% above normal, 2mm

Question 14

2+ pitting edema

Answer 14

deeper pit after pressing (4mm)
lasts longer than 1 second
fairly normal contour

Question 15

3+ pitting edema

Answer 15

deep pit (6mm)
remains several seconds after pressing
skin swelling obvious by general impression

Question 16

4+ pitting edema

Answer 16

deep pit (8mm) 
remains for a prolonged time after pressing possibly minutes 
frank swelling

Question 17

Brawny Edema

Answer 17

fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, no pitting, tissue palpates as firm

Question 18

Primary skin lesion

Answer 18

arises from normal skin

macule, papule, nodule, tumor, wheal

Question 19

Secondary skin Lesion

Answer 19

changes in the primary lesion

erosions, ulcers, fissures; loss of skin surface, crust/scale: material on skin surface.

Question 20

Stage 1 pressure ulcer

Answer 20

epidermis layer, no skin breakdown, non blanchable redness

Question 21

stage 2 pressure ulcer

Answer 21

epidermis/dermis layers; partial thickness skin breakdown

Question 22

stage 3 pressure ulcer

Answer 22

subcutaneous layer; full thickness; chemical debridement

Question 23

stage 4

Answer 23

full thickness with muscle/bone/tendon exposed; surgical debridement

Question 24

unstageable

Answer 24

base of ulcer is covered by slough/eschar

Question 25

hypothermia

Answer 25

95-96.7 degrees

Question 26

afebrile (without fever)

Answer 26

96.8-100.4

Question 27

Febrile, hyperthermia, pyrexia

Answer 27

100.5-104

Question 28

hyperpyrexia

Answer 28

greater than 106