Module 4- The Basics and Surface Assessment

Question 1

Blanchable

Answer 1

reddened area that turns pale under applied light pressure

Question 2

Non-blanchable

Answer 2

an area of redness that does not blanch under applied light pressure

Question 3

blue skin

Answer 3

cyanosis resulting from poor circulation or inadequate oxygenation of the blood.

Question 4

purple skin

Answer 4

deep tissue pressure injury

Question 5

Red skin

Answer 5

infection or inflammation
could also include cellulitis or dermatitis
erythema

Question 6

Cellulitis

Answer 6

a common, potentially serious bacterial skin infection. The affected skin is swollen and inflamed and is typically painful and warm to the touch. Cellulitis usually affects the lower legs, but it can occur on the face, arms and other areas.

Question 7

Erythema

Answer 7

abnormal red color
may indicate underlying infection
indicative of stage 1 pressure injuries if over bony prominence
may be a 1st degree burn

Question 8

Pediatric multisystem inflammatory syndrome

Answer 8

purplish lesion on toes and feet, rash

Question 9

white skin

Answer 9

reynaud’s: usually triggered by cold temperatures, anxiety or stress. The condition occurs because your blood vessels go into a temporary spasm, which blocks the flow of blood. This causes the affected area to change colour to white, then blue and then red, as the bloodflow returns.

Question 10

Black

Answer 10

necrosis/gangrene

Question 11

Yellow

Answer 11

jaundice

Question 12

hemosiderin staining

Answer 12

occurs when capillaries begin to leak. This can be due to a wound, a broken bone, a surgical incision or other types of trauma. It is also associated with certain illnesses that affect circulation.

Question 13

What are the ABC for malignancies of the skin

Answer 13

A-asymmetries
B-borders- ragged, notched, blurred
C-Color- nonuniform color,
D-Diameter- usually greater than 6mm
E-Evolving- grows and changes over time

Question 14

What is the A for nail melanoma

Answer 14

age range 20-90 years
african american, native american, asian

Question 15

what is the B for nail melanoma

Answer 15

band of brown or black pigment in nail OR
breadth of >3mm
OR
Border that is irregular/blurred

Question 16

what is the C in nail melanoma

Answer 16

change in size or growth rate of nail band
OR
Lack of change in irregular nail despite treatement

Question 17

What is the D in nail melanoma

Answer 17

Digit involved
pigmented band on a single digit is more suspicious
dominant hand involved more common

Question 18

what is the E in nail melanoma

Answer 18

Extension of brown or black pigment to the side or base of the nail

Question 19

what is the F in nail melanoma

Answer 19

Family history or personal history of melanoma or irregular moles

Question 20

a disease that happens when the immune system attacks hair follicles and causes hair loss

Answer 20

alopecia areata

Question 21

hair loss from continuous pulling on the hair follicles

Answer 21

traction alopecia

Question 22

Skin color Hemosiderin

Answer 22

brownish-purple color
usually seen in “gaiter area” of leg
common in chronic venous insufficiency

Question 23

Small (1-2mm; <3 mm) red or purple spots on the skin

Answer 23

petechia

Question 24

> 3 mm red or purple spot on the skin

Answer 24

purpura

Question 25

> 1 cm commonly called a bruise

Answer 25

ecchymosis

Question 26

do petechia, purpura and ecchymoses blanch with pressure

Answer 26

yes

Question 27

changes in skin color and texture may be a sign of what

Answer 27

infection

Question 28

defined as excess fluid in the interstitial tissue

Answer 28

edema

Question 29

Localized edema is a sign of ____ and is a result of ____ response in the immediate wound area

Answer 29

infection and inflammatory response

Question 30

what are the descriptions that go along with 1+, 2+, 3+ and 4+ grading of edema

Answer 30

1+ barely perceptible slight depression
2+ skin rebounds <15 sec 0.0-0.6 cm depression
3+ skin rebounds in 14-30 sec 0.6-1.3 cm of depression
4+ skin rebounds in >30 sec 1.3-2.5 cm of depression

Question 31

what is skin induration edema

Answer 31

deep thickening of the skin that can result from edema, inflammation, or infiltration, including by cancer. Diagnosis of skin induration is made by palpation (feeling the area) and assessing whether the raised area has a hard, resistant feeling.

Question 32

What are the 5 signs/symptoms of acute inflammation

Answer 32

rubor- redness
fumor- swelling
calsor- heat
Dolor-pain
function laesa- loss of function

Question 33

what are signs of infection

Answer 33

odor
pain

palpation
systemic changes
wound cultures