Module 4- The Basics and Surface Assessment Flashcards
Blanchable
reddened area that turns pale under applied light pressure
Non-blanchable
an area of redness that does not blanch under applied light pressure
blue skin
cyanosis resulting from poor circulation or inadequate oxygenation of the blood.
purple skin
deep tissue pressure injury
Red skin
infection or inflammation
could also include cellulitis or dermatitis
erythema
Cellulitis
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.
Erythema
abnormal red color
may indicate underlying infection
indicative of stage 1 pressure injuries if over bony prominence
may be a 1st degree burn
Pediatric multisystem inflammatory syndrome
purplish lesion on toes and feet, rash
white skin
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.
Black
necrosis/gangrene
Yellow
jaundice
hemosiderin staining
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.
What are the ABC for malignancies of the skin
A-asymmetries
B-borders- ragged, notched, blurred
C-Color- nonuniform color,
D-Diameter- usually greater than 6mm
E-Evolving- grows and changes over time
What is the A for nail melanoma
age range 20-90 years
african american, native american, asian
what is the B for nail melanoma
band of brown or black pigment in nail OR
breadth of >3mm
OR
Border that is irregular/blurred
what is the C in nail melanoma
change in size or growth rate of nail band
OR
Lack of change in irregular nail despite treatement
What is the D in nail melanoma
Digit involved
pigmented band on a single digit is more suspicious
dominant hand involved more common
what is the E in nail melanoma
Extension of brown or black pigment to the side or base of the nail
what is the F in nail melanoma
Family history or personal history of melanoma or irregular moles
a disease that happens when the immune system attacks hair follicles and causes hair loss
alopecia areata
hair loss from continuous pulling on the hair follicles
traction alopecia
Skin color Hemosiderin
brownish-purple color
usually seen in “gaiter area” of leg
common in chronic venous insufficiency
Small (1-2mm; <3 mm) red or purple spots on the skin
petechia
> 3 mm red or purple spot on the skin
purpura
> 1 cm commonly called a bruise
ecchymosis
do petechia, purpura and ecchymoses blanch with pressure
yes
changes in skin color and texture may be a sign of what
infection
defined as excess fluid in the interstitial tissue
edema
Localized edema is a sign of ____ and is a result of ____ response in the immediate wound area
infection and inflammatory response
what are the descriptions that go along with 1+, 2+, 3+ and 4+ grading of edema
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
what is skin induration edema
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.
What are the 5 signs/symptoms of acute inflammation
rubor- redness
fumor- swelling
calsor- heat
Dolor-pain
function laesa- loss of function
what are signs of infection
odor
pain
palpation
systemic changes
wound cultures
