Skin Assessment and Wounds Flashcards
Itching
Pruritus
How to palpate temperature of skin
Back of hands
Pale skin
Pallor
Bluish tone, deoxygenated blood
Cyanosis
Intense red color of skin
Erythema
Yellowish tone, increased bilirubin
Jaundice
Liver spots
Senile lentigines
Dry skin
Xerosis
Skin tags
Acrohordons
No thickness, less than 1 cm (eg. freckle)
Macule
No thickness, greater than 1 cm
Patch
Palpable elevations < 1 cm (moles, warts)
Papule
Papules combining > 1 cm
Plaque
Solid, elevated mass larger than 1 cm (extends deeper into dermis)
Nodule
Mass greater than a few cm in diameter (deeper into dermis)
Tumor
Superficial, raised, transient (eg. mosquito bites)
Wheal
Hives
Uticaria
Blisters
Vesicle + bulla
Fluid cavity in dermis/subq
Cyst
ABCDE for mole inspection
Asymmetry, border, color, diameter, evolving
Stage 1 pressure injury
Non-blanchable, intact skin
Stage 2 pressure injury
Partial-thickness skin loss, exposed dermis
Stage 3 pressure injury
Full thickness skin loss (down to subq)
Stage 4 pressure injury
Full thickness skin loss, loss of tissue (down to bone or muscle)
Unstageable
Black and can’t see how deep, use ultrasound
What does the braden scale measure?
Moisture, sensory, mobility, nutritional status, friction and shear
Score of ___ or less represents high risk on the Braden scale
12
BYR classification
Black - needs debridement
Yellow - needs to be cleaned
Red - needs to be protected
Incision pops open
Dehiscence
Incision pops open, contents spill out
Evisceration
What to do in case of evisceration
Semi-fowlers position, cover in sterile saline, call code
How to obtain a specimen of wound?
Swab red, healthy tissue
How early do you premedicate before dressing change?
Pain
Do dressing changes need to be sterile?
Yes, usually use normal saline (check the order!)
Food that promotes wound healing
Protein, vitamin C, calcium, magnesium, zinc
