Exam 2: Skin, Hair, and Nails Flashcards
What is the ABCDE rule? Describe what it is used to assess for and what each acronym means.
The ABCDE rule is a basis on which you analyze a patients risk for skin cancer and are more often used as guidlines to assess pigmented lesions suspected of being cancerous. In this case you want to look for;
Asymmetry- Is the pigmentation even? is the shape of the lesion even? Are the two halves of the lesion symmetrical?
Border- What are the edges of the lesion like? Cancerous tumors are often indicated by irregular and ill defined edges. Such as scallops, notches or ragged edges.
Color- Note the color of the lesion, what color it is and any variations of color throughout the lesion.
Diameter- How big is the lesion? Typically anything larger than 6mm is considered abnormal and would warrant further investigation,
Elevation or Evolution-Is it raised? Upon a time-lapsed assessment have their been any changes to the lesion?
What is skin tugor?
It is the skin’s elasticity.
How do you assess skin tugor?
To assess Skin tugor or mobility simply pinch a large fold of the skin on the anterior chest under the clavicle and observe its ability to return to place. Normal findings are often the skin returns promptly to place with very slight delay.
Describe the 4 stages of Pressure Ulcers.
Stage one: Is considered Nonblanchable and noted by localized redness, intact and skin.
Stage Two: Skin is now broken, but only dermis deep. It appears more like a blister with no deep tissue visible.
Stage Three: Cratered in appearance with Sub Q fat and granular tissue now visible and borders caving into the wound.
Stage 4: Crater has now deepened enough to expose muscle, tendon, and even bone. There may even appear to be slough or eschar which would signal the need for more urgent and surgical treatments.
What are factors that can cause poor skin tugor
Factors that negatively effect skin tugor involve;
Dehydration
Edema
Etreme weight loss
Where do you test skin tugor on infants?
In the abdomen.
What is the nickname for poor tugor?
Tenting
What is skin tugor typically like in an older adult patient?
Older adults often experience poor skin tugor or “Tenting”. This is due to the natural loss of collagen with age and is another risk factor in shearing/ Development in pressure ulcers in Older Adult pt’s.
