Skin+Peripheral Vascular Flashcards
What is the purpose of the skin and vascular system?
Feel all pulses and ensure heart and blood flow is intact
Describe the general purpose of the lymphatic system
Maintain fluid balance in the body by collecting excess fluid from tissues and returning it to blood
Pallor
Pale
Erythema
Red
Cyanosis
Blue
Jaundice
Yellow
Location of carotid artery
Neck
Location of brachial pulse
Upper arm
Location of radial pulse
Thumb side of lower arm
Location of femoral pulse
Upper leg
Location of popliteal pulse
Knee
Location of posterior tibial pulse
Towards back of ankle
Location of dorsalis pedis pulse
Top of foot
Arteries
Elastic walled vessels that carry blood from heart through the body
Femoral artery
Chief artery of the anterior inner thigh
Veins
Tubular branching vessels that carry blood from capillaries to heart
Pulse
Regular expansion of an artery caused by ejection of blood into arterial system
Edema
Swelling
Embolus
Abnormal particle (mass) circulating in the blood
Thrombus
Clot of blood formed within a blood vessel and remains attached
Thrombus
Clot of blood formed within a blood vessel and remains attached
TED hose
Thromoboembolic deterrent hose used to apply compression to a superficial leg vein and prevent the formation of blood clots
SCDs
Sequential compression devices used as mechanical prophylaxis in the prevention of the formation of blood clots
Virchow’s Triad
3 factors that place a person at risk for the formation of blood clots: blood stasis and hypercoaguability and injury to the vessel wall
Doppler probe
Transducer applied to the skin to assess blood flow and locate arteries
Paresthesia
Sensation of prickling, tingling, on skin with no objective cause
What are the 5 Ps to assess compromised circulation
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
What is the largest organ in the body
Skin which is the protective barrier
What is included with the skin exam portion of the bedside assessment
Inspection
Palpation
What is the order of the layers of the skin
Epidermis
Dermis
Subcutaneous tissue
Muscle
Bone
What are 3 examples of lesions to the skin
Freckles
Moles
Sores
Skintags
Insect bites
Pressure ulcer
Tissue injury resulting from prolonged pressure on the skin
Lesion
Abnormal change in structure of an organ or body part
Nevus
Congenital highly pigmented area of skin, flat or raised
Lice
Small wingless flat insect, sucks blood, gets in hair
Clubbing
Bulbous enlargement of the ends of one or more fingers or toes
Pigmentation
Deposition or presence of pigment
Striae
Stretch marks
Keloid
Thick scar resulting from excessive growth of fibrous tissue
Pruritis
Itching sensation on skin
Turgor
State of turgidity and rigidity of cells or tissues
Necrotic
Death of localized area of tissue
Diaphoresis
Profuse perspiration
Dehydration
Abnormal depletion of body fluids
Texture
Visual or tactile surface characteristics of appearance
Dorsal
Relating to or situated near or on the back
Ventral
Relating to belly or anterior side
Hypothermia
Subnormal temperature of thebody
Hyperthermia
Exceptionally high fever
Semi fowlers position
Supine position with HOB raised 30-45 degrees
High fowlers position
Supine position with HOB raised 90 degrees
Lateral position
Side, lying on side
What are the steps of the BEDSIDE peripheral vascular exam?
Inspect upper and lower extremities for symmetry of size
Palpates for radial pulses
Palpates capillary refill
Palpates dorsalis pedal pulses
Palpates lower extremities for edema
What assessment techniques are used during the BEDSIDE peripheral vascular exam
Inspection and palpation
List AND describe the grading scale used to evaluate pulses
0Absent
1Weak
2Normal
3Bounding
Embolus
Travels
Thrombus
Doesn’t move
What are the 5Ps
Pain
Pallor
Paresthesia
Pulselessness
Paralysis
List AND describe the grading scale used to evaluate edema
1/4 mild pitting, slight indentation, no perceptible swelling
2/4: moderate pitting, indentation, subsides rapidly
3/4: deep pitting, indentation remains short time, legs look swollen
4/4: very deep pitting, indentation lasts a long time, legs grossly swollen
What are some subjective questions that relate to the peripheral vascular exam
Have you had any recent swelling
Do you have a history of blood clots
Any changes in sensation, numbness, or tingling
What assessment techniques are used during the skin exam
Inspection, Palpation, inspection
What are the 3 steps of the BEDSIDE SKIN exam
Inspect upper and lower extremities for color and intactness
Palpates upper and lower extremities with light touch for texture, temperature,moisture
Inspects skin condition for patient lying in supine position for color and intactness
What are three meaningful subjective questions that relate to the skin exam
History of skin disease
Change in pigmentation/moles
Any new rash or lesions
How does the nurse specifically assess skin temperature during the skin exam?
Palpates forearms and tibias
What 3 findings are being assessed on the forearms and tibias during the BEDSIDE exam
Temperature
Texture
Moisture
Which 2 findings are being assessed on the upper and lower extremities during the BEDSIDE skin exam
Color and intactness
Which 2 findings are being assessed on the upper and lower extremities during the BEDSIDE skin exam
Color and intactness
Describe 3 conditions that put a patient at risk for skin breakdown
Wheelchair bound
Paralysis
Coma
What 2 findings are being assessed during inspection of the bony prominences during the skin exam
Color intactness
Skin breakdown
What is the difference between the peripheral vascular exam and the skin exam
Circulation
Intactness and abnormalities
What are the 6 places we check for Semi-fowlers position
Coccyx
Heels
Sacral
Elbow
Scapula
Occipital
What 6 places do we check for supine position
Heels
Sacrum
Spine
Elbows
Scapula
Occipital
What 5 places do we check for lateral position
Ankle
Knee
Hip
Scapula
Ear
Describe specifically how to assess AND evaluate capillary refill
Depress/blanch TIP of nail beds on SAME FINGER ON EACH HAND release and note time for color return
Typically refill within a fraction of a second or 2 <2 seconds
