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Integumentary 1 - Midterm > Skin Assessment - Class 2 > Flashcards

Skin Assessment - Class 2 Flashcards

1
Q

thorough skin assessment is

A

paramount

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2
Q

what is key

A

prevention

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3
Q

early intervention is

A

critical

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4
Q

what should we identify

A

threats to skin integrity

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5
Q

visual inspection…

A

alone is not sufficient

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6
Q

parts of skin assesment

A

touch

observation (look with good lighting)

talk/document

smell

listen

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7
Q

2 overall assessments

A

subjective and objective

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8
Q

subjective assesment

A

subjective (RFs)

medical history

medications

nutrition

smoking, drugs, alc use

activity level

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9
Q

medical history –> subjective

A

diabetes

hypertension

renal dz

etc.

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10
Q

nutrition –> subjective

A

obesity/fragility

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11
Q

activity level –> subjective

A

exercise

mobility

ADL

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12
Q

objective skin assessment components

A

skin integrity

ethnicity

sensory status

moisture

atrophic changes

turgor/texture

nail composition and hair quality

edema, color and temp variations

observe skin folds

vascular status

lesions

callus

scar

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13
Q

skin integrity

A

is the skin in tact or does it present with injury

classify stage (if there is a pressure ulcer)

describe –> shape, size, depth, etc.

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14
Q

ethnicity

A

note skin tone and dermatological variants

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15
Q

sensory status

A

intact or altered

light touch –> location –> specific tests and soft tissue status

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16
Q

moisture

A

dry or moist to touch

normal

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17
Q

dry –> moisture

A

xerosis

flaking

scales

fissures

rash

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18
Q

wet –> moisture

A

sweat

weeping edema

incontinence

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19
Q

atrophic changes

A

shiny, hairless extremities

recommend vascular consult

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20
Q

turgor/texture

A

tent the skin on dorsum of hand to test

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21
Q

turgor

A

skin elasticity

normal v. delayed

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22
Q

texture

A

how does the skin feel?

normal, watery, softly pitting, brawny/fibrotic, hard/noncompressible

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23
Q

nail composition and hair quality

A

both are extensions of the skin

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24
Q

nails

A

color

shape

clubbing

thickness

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25
Q

hair

A

distribution

hair loss

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26
Q

what can color of the nails tell you

A

pale - anemia

half pink and half white - kidney dysfxn

yellow - lung dz or nail infection

half moons are red - lupus, heart dx, etc.

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27
Q

clubbing of the nail

A

nails are wider

chronic low O2

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28
Q

weak nails

A

vitamin B, calcium, iron deficient

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29
Q

thick nails

A

fungal infection

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30
Q

vertical ridges on nail

A

common as we age

decrease in vitamins A, B, D, keratin, etc.

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31
Q

horizontal ridges on nail

A

Beau’s lines

dysfxn of thyroid

vitamin deficient

injury

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32
Q

what is glaborous hair

A

non hairy regions

palms, soles

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33
Q

what is non glaborous

A

hairy regions

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34
Q

hirsutism hair

A

excessive body hair

35
Q

alopecia

A

hair loss

thyroid

protein deficiency

36
Q

hair shedding

A

thyroid dysfxn

hormone dysfxns

iron deficiencies

37
Q

grey hair

A

stress or genetic

38
Q

dandruff

A

sebhorric dermatitis

fungus

39
Q

edema

A

note location

pitting or non-pitting

40
Q

color

A

white, red, blue, yellow, black

41
Q

pigmentation

A

pallor

cyanosis

jaundice

hyper/hypo

42
Q

temp

A

normal, cool, warm or hot to touch

compare to the other side

43
Q

observe skin folds

A

breast tissue, abdominal tissue, skin creases

44
Q

what to look for in skin folds

A

skin breakdown

yeast/fungal infections

foreign objects

45
Q

callus

A

indicates area(s) of high pressure or repetitive stress/trauma

46
Q

scar –> normal trophic

A

normal

47
Q

scar –> hypertrophic

A

high

w/in margins

48
Q

scar –> keloid

A

high

beyond margins

49
Q

scar –> immature

A

darker/red/raised/move as one

piece/immobile/sensitive/insensate

50
Q

scar –> mature

A

lighter/flat. segmental movement/ mobile/ normal sensation

51
Q

vascular status

A

look, listen and feel for color changes, doppler, palpate pulses, capillary refill, ABI and rubor of deficiency

52
Q

lesions

A

rashes, scars, bruising, hemosiderin, nevi-birthmark or mole, etc.

53
Q

document –> lesions

A

locations

describe presentation

formulate working clinical dx

denote anything unusual or suspicious

54
Q

pulses

A

femoral

popliteal

dorsalis pedis

post tibial

55
Q

pulse grades

A

0-4+

56
Q

pulse grade –> 0

A

no pulse

57
Q

pulse grade –> 1+

A

barley felt

58
Q

pulse grade –> 2+

A

diminished

59
Q

pulse grade –> 3+

A

normal

60
Q

pulse grade –> 4+

A

bounding

61
Q

assessment of pressure ulcers uses

A

braden scale

62
Q

braden scale looks for

A

early identification of pts at risk for forming pressure sores

63
Q

braden scale has

A

6 subscales

64
Q

subscales of the braden scale

A

sensory perception

skin moisture

activity

mobility

friction and shear

nutritional status

65
Q

the lower the braden scale

A

higher the risk of pressure sore development

66
Q

high risk –> braden score

A

total score of 6-12

67
Q

moderate risk –> braden score

A

total score 13-14

68
Q

mild risk –> braden scale

A

15-18

69
Q

no risk –> braden scale

A

19-23

70
Q

wagner scale

A

for diabetic ulcers

asses ulcer depth and foot lesions in diabetic feet

71
Q

how often to diabetic foot ulcers occur in those w/ diabetes

A

15%

72
Q

what doesnt the wagner scale describe

A

infected or ischemic wounds

73
Q

wagner scale –> grade 1

A

partial or full thickness ulcer

superficial

74
Q

wagner scale –> grade 2

A

deep ulcer extended to lig, tendon, joint capsule, bone or deep fascia

w/o abscess or osteomyelitis

75
Q

wagner scale –> grade 3

A

deep abscess

osteomyelitis or joint sepsis

76
Q

wagner scale –> grade 4

A

partial foot gangrene

77
Q

wagner scale –> grade 5

A

whole foot gangrene

78
Q

university of texas wound class system

A

newer

more descriptive v. wagner

assesses wounds in the diabetic foot

79
Q

texas –> grade 0

A

pre/post ulcerative state

80
Q

texas –> grade 1

A

superficial wound

no tendon, capsule, bone involvement

81
Q

texas –> grade 2

A

wound penetrates to tendon or capsule

82
Q

texas –> grade 3

A

wound penetrates to bone or joint

83
Q

what does the texas class system include

A

subsets to categorize infection and ischemia

Integumentary 1 - Midterm (23 decks)

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