Skin Flashcards
For inspection, look for
pallor
redness
wounds
When documenting a wound should you describe it or label it as the type of wound
just describe it- length, width, depth, square/oval/round, discharge/exudate, color, odor
When describing never use the word
approximately
What measurement scale should be used
cm
What is a fistula
abnormal connection between two hollow spaces
What is blanchable
if you press on it the color will go away
What is a stage 1 pressure ulcer
non-blanchable redness, closed
What is a stage 2 press ulcer
open, red, and shallow wound
partial skin loss of the dermis
What is a stage 3 press ulcer
open, subQ fat is visible
Do you document the redness around the wound with the description of the wound
no, describe the redness around the wound separately
What is a stage 4 press ulcer
open, usually tunneling, down to the bone, might be eschar
If there is eschar covering up enough of the wound to where you can’t see any fat or bone what is it classified as
unstable
For palpation assess for
diaphoresis
temp
turgor
texture (weak?)
What is one of the first things that you should almost always do if your patient is getting worse
get a blood sugar
