NURS 301 1st exam Flashcards
what guides an assessment
questions which give you the subjective about the patient
episodic health assessment
usually done when a patient is following up with a healthcare provider for a previously identified problem. usually once a year
screening health assessment
example would be diabetes
what percent of an adult body weight is skin?
16% heaviest organ of our body
control mechanisms of the skin
thermoregulation and fluid electrolyte balance
what vitamin does the skin produce
vitamin D
integumentary system can provide vital information on
patients health status and whether the functioning of the total body system if adequately performing
pruritus
itchy skin
OLDCARTS
onset, location, duration, characteristics, aggravation or alleviation, related systems, treatment by the patient, severity
IPPA
inspection, palpation, percussion, auscultation
perspiration is normal on
face, hands, axillae, and skin folds
what do you test during skin assessment
skin texture, skin thickness, edema
skin texture
check smoothness/firmness and elasticity
edema
can be pitting or non-pitting. best place to assess is the tibial plate
questions to ask when assessing edema
Did your shoes fit okay today? do your legs feel swollen?
inspect the skin surfaces for
skin breakdown on bony prominences, lesions, tattoos, scars, rashes, bruising
ABCDEF format
asymmetric, borders, colors, diameter, elevation, and feeling
when assessing skin conditions always describe using
ABCDEF format
Braden skin scale
tool that is used to determine a patients risk in developing a pressure ulcer. based off 6 criteria: sensory perception, moisture, activity, mobility, nutrition, friction and shear
scoring with Braden scale
each category is worth 1-4 except friction and shear which is 1-3. 15-18=mild risk, 13-14 = moderate risk, 10-12.= high risk, and less than 9 = very high risk
populations at risk for pressure ulcers
people in casts or cervical collars, immobilizing devices, nasal cannulas, wound vacs, any drains
stage 1 pressure ulcer
purple/maroon discolored area/blood filled blister. the skin remains intact, nonblanchable redness
stage 2 pressure ulcer
partial thickness loss of dermis, looks like an open blister, no slough
stage 3 pressure ulcer
full thickness tissue loss, fat may be visible but not bone or tendon, can include undermining or tunneling