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NURS 295 > Skin Assessment and Wounds > Flashcards

Skin Assessment and Wounds Flashcards

1
Q

Itching

A

Pruritus

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2
Q

How to palpate temperature of skin

A

Back of hands

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3
Q

Pale skin

A

Pallor

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4
Q

Bluish tone, deoxygenated blood

A

Cyanosis

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5
Q

Intense red color of skin

A

Erythema

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6
Q

Yellowish tone, increased bilirubin

A

Jaundice

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7
Q

Liver spots

A

Senile lentigines

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8
Q

Dry skin

A

Xerosis

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9
Q

Skin tags

A

Acrohordons

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10
Q

No thickness, less than 1 cm (eg. freckle)

A

Macule

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11
Q

No thickness, greater than 1 cm

A

Patch

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12
Q

Palpable elevations < 1 cm (moles, warts)

A

Papule

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13
Q

Papules combining > 1 cm

A

Plaque

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14
Q

Solid, elevated mass larger than 1 cm (extends deeper into dermis)

A

Nodule

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15
Q

Mass greater than a few cm in diameter (deeper into dermis)

A

Tumor

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16
Q

Superficial, raised, transient (eg. mosquito bites)

A

Wheal

17
Q

Hives

A

Uticaria

18
Q

Blisters

A

Vesicle + bulla

19
Q

Fluid cavity in dermis/subq

A

Cyst

20
Q

ABCDE for mole inspection

A

Asymmetry, border, color, diameter, evolving

21
Q

Stage 1 pressure injury

A

Non-blanchable, intact skin

22
Q

Stage 2 pressure injury

A

Partial-thickness skin loss, exposed dermis

23
Q

Stage 3 pressure injury

A

Full thickness skin loss (down to subq)

24
Q

Stage 4 pressure injury

A

Full thickness skin loss, loss of tissue (down to bone or muscle)

25
Q

Unstageable

A

Black and can’t see how deep, use ultrasound

26
Q

What does the braden scale measure?

A

Moisture, sensory, mobility, nutritional status, friction and shear

27
Q

Score of ___ or less represents high risk on the Braden scale

A

12

28
Q

BYR classification

A

Black - needs debridement
Yellow - needs to be cleaned
Red - needs to be protected

29
Q

Incision pops open

A

Dehiscence

30
Q

Incision pops open, contents spill out

A

Evisceration

31
Q

What to do in case of evisceration

A

Semi-fowlers position, cover in sterile saline, call code

32
Q

How to obtain a specimen of wound?

A

Swab red, healthy tissue

33
Q

How early do you premedicate before dressing change?

A

Pain

34
Q

Do dressing changes need to be sterile?

A

Yes, usually use normal saline (check the order!)

35
Q

Food that promotes wound healing

A

Protein, vitamin C, calcium, magnesium, zinc

36
Q
A

NURS 295 (4 decks)

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