Chapter 30 Integumentary and Peripheral Vascular Systems Flashcards
What type of tool/scale do you use to assess risk of pressure ulcers?
Braden scale
Should assessing the integumentary and peripheral systems been done together?
Yes
Examples of questions to ask when reviewing two systems are:
Have you notice changes in skin color?
Do you have a rash?
Is skin excessively dry or oily?
Moles or lesions?
The description of pallor and indication are:
Loss of color (face, conjunctive, nail beds, palms)
Anemia or lack of blood flow
The description of cyanosis and indication are:
Bluish (nail beds, lips, mouth skin)
Hypoxia or impaired venous return.
The description of jaundice and indication are:
Yellow to orange (skin, sclera, mucous membrane)
Liverdysfunction, red blood cell destruction.
The description of erythema and indication are:
Redness (face trauma, and pressure sore areas)
Inflammation, localized vasodilation
What does brown pigmentation changes indicate?
Venous insufficiency.
What does shiny and translucent skin without hair on toes and foot indicate?
Arterial insufficiency.
When palpating the peripheral pulses, what two things should you be looking?
Strength (amplitude) and equality (symmetry)
Strength amplitude should be _________ from beat to beat.
Same
Grade strength for peripheral pulse is:
0 absent, unable to palpate 1+ diminished, weaker than expected 2+ brisk, expected 3+ increased 4+ full volume, bounding
Palpate pulse sites bilaterally to make comparisons with the exception of what area?
Carotid arteries
Name locations of seven pulses:
Carotid Radial Brachial Femoral Popliteal (behind knee) Dorsalis pedis Posterior tibial (behind and below the medial malleolus of the ankles)
What should you inspect the peripheral veins for?
Varicosities, redness, swelling.
What is edema?
Fluid in tissues causing swollen, tight and shiny skin surface.
How should Edema be assessed?
Discoloration
Location
Tenderness
Measure extremities circumference of swollen body area and compare both sides.
Lesions should be examined for what?
Size Color Shape Consistency Elevation Location Distribution Configuration Tenderness Fluid and drainage.
Primary lesions arise from what type of skin tissue?
Healthy skin tissue.
What is a macule lesion?
Nonpalpable, skin color change, smaller than 1 cm
Ex. Freckles
What is a papule lesion?
Palpable, circumscribed, smaller than 1 cm
Ex. Elevated nevus
What is a nodule/tumor?
Palpable, circumscribed, deep, firm, 1 to 2.
Ex. Wart
What is a vesicle?
Serous fluid-filled, smaller than 1 cm
Ex. Blister, herpes simplex, varicella
What is a pustule?
Pus-filled
Ex. Acne
What is a tumor?
Solid mass, deep, larger than 1 to 2 cm.
Ex. Epithelioma
What is a wheal?
Palpable, irregular borders, edematous
Ex. Insect bite
What does secondary lesions result from?
A change in a primary lesion.
Name the five secondary lesions.
Erosion Crust Scale Fissure Ulcer
Name the seven primary lesions.
Macule Papule Nodule Vesicle Pustule Tumor Wheal
What is an erosion?
Lost epidermis, moist surface, no bleeding
Ex. Raptured vesicle
What is crust?
Dried blood, serum or pus
Ex. Scab
What is a fissure?
Linear crack
Ex. Tinea pedis
What is an ulcer?
Loss of epidermis and dermis with possible bleeding, scarring.
Ex. Venous stasis ulcer, pressure ulcer.
Examples of skin lesions for children are:
Diaper dermatitis
Intertrigo
Impetigo
Atopic dermatitis (eczema)
Examples of skin lesions for adults are:
Primary contact dermatitis
Tinea pedis (ringworm of the foot)
Psoriasis
Labial herpes simplex
Examples of skin lesions for older adults are:
Lentigines (liver spots)
Seborrheic keratosis
Arochordons (skin tags)
Sebaceous hyperplasia
What do vascular lesions result from?
Aging changes or blood-vessel damage in or near the skin.
What are the six vascular lesions?
Spider angioma Cherry angioma Spider vein Petechia/purpura Ecchymosis Hematoma
What is spider angioma?
Red center with radiating red legs, up to 2 cm. possibly raised.
What is cherry angioma?
Red 1 to 3 cm, round, possibly raised
What is a spider vein?
Bluish, spider-shaped or linear up to several inches in size.
What is petechia/purpura?
Deep reddish purple, flat, petechiae 1 to 3 mm, purpura larger than 3 mm
What is ecchymosis?
Purple fading to green or yellow over time, variable in size, flat
What is a hematoma?
Raised ecchymosis
What are expected changes in the peripheral vascular system with age?
Thicker more rigid peripheral blood vessel walls with a narrowed lumen leading to poor peripheral circulation
Higher systolic blood pressure.
