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NUR 223 > Skin+Peripheral Vascular > Flashcards

Skin+Peripheral Vascular Flashcards

1
Q

What is the purpose of the skin and vascular system?

A

Feel all pulses and ensure heart and blood flow is intact

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2
Q

Describe the general purpose of the lymphatic system

A

Maintain fluid balance in the body by collecting excess fluid from tissues and returning it to blood

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3
Q

Pallor

A

Pale

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4
Q

Erythema

A

Red

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5
Q

Cyanosis

A

Blue

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6
Q

Jaundice

A

Yellow

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7
Q

Location of carotid artery

A

Neck

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8
Q

Location of brachial pulse

A

Upper arm

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9
Q

Location of radial pulse

A

Thumb side of lower arm

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10
Q

Location of femoral pulse

A

Upper leg

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11
Q

Location of popliteal pulse

A

Knee

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12
Q

Location of posterior tibial pulse

A

Towards back of ankle

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13
Q

Location of dorsalis pedis pulse

A

Top of foot

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14
Q

Arteries

A

Elastic walled vessels that carry blood from heart through the body

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15
Q

Femoral artery

A

Chief artery of the anterior inner thigh

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16
Q

Veins

A

Tubular branching vessels that carry blood from capillaries to heart

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17
Q

Pulse

A

Regular expansion of an artery caused by ejection of blood into arterial system

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18
Q

Edema

A

Swelling

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19
Q

Embolus

A

Abnormal particle (mass) circulating in the blood

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20
Q

Thrombus

A

Clot of blood formed within a blood vessel and remains attached

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21
Q

Thrombus

A

Clot of blood formed within a blood vessel and remains attached

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22
Q

TED hose

A

Thromoboembolic deterrent hose used to apply compression to a superficial leg vein and prevent the formation of blood clots

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23
Q

SCDs

A

Sequential compression devices used as mechanical prophylaxis in the prevention of the formation of blood clots

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24
Q

Virchow’s Triad

A

3 factors that place a person at risk for the formation of blood clots: blood stasis and hypercoaguability and injury to the vessel wall

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25
Q

Doppler probe

A

Transducer applied to the skin to assess blood flow and locate arteries

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26
Q

Paresthesia

A

Sensation of prickling, tingling, on skin with no objective cause

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27
Q

What are the 5 Ps to assess compromised circulation

A

Pain
Pallor
Pulselessness
Paresthesia
Paralysis

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28
Q

What is the largest organ in the body

A

Skin which is the protective barrier

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29
Q

What is included with the skin exam portion of the bedside assessment

A

Inspection
Palpation

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30
Q

What is the order of the layers of the skin

A

Epidermis
Dermis
Subcutaneous tissue
Muscle
Bone

31
Q

What are 3 examples of lesions to the skin

A

Freckles
Moles
Sores
Skintags
Insect bites

32
Q

Pressure ulcer

A

Tissue injury resulting from prolonged pressure on the skin

33
Q

Lesion

A

Abnormal change in structure of an organ or body part

34
Q

Nevus

A

Congenital highly pigmented area of skin, flat or raised

35
Q

Lice

A

Small wingless flat insect, sucks blood, gets in hair

36
Q

Clubbing

A

Bulbous enlargement of the ends of one or more fingers or toes

37
Q

Pigmentation

A

Deposition or presence of pigment

38
Q

Striae

A

Stretch marks

39
Q

Keloid

A

Thick scar resulting from excessive growth of fibrous tissue

40
Q

Pruritis

A

Itching sensation on skin

41
Q

Turgor

A

State of turgidity and rigidity of cells or tissues

42
Q

Necrotic

A

Death of localized area of tissue

43
Q

Diaphoresis

A

Profuse perspiration

44
Q

Dehydration

A

Abnormal depletion of body fluids

45
Q

Texture

A

Visual or tactile surface characteristics of appearance

46
Q

Dorsal

A

Relating to or situated near or on the back

47
Q

Ventral

A

Relating to belly or anterior side

48
Q

Hypothermia

A

Subnormal temperature of thebody

49
Q

Hyperthermia

A

Exceptionally high fever

50
Q

Semi fowlers position

A

Supine position with HOB raised 30-45 degrees

51
Q

High fowlers position

A

Supine position with HOB raised 90 degrees

52
Q

Lateral position

A

Side, lying on side

53
Q

What are the steps of the BEDSIDE peripheral vascular exam?

A

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

54
Q

What assessment techniques are used during the BEDSIDE peripheral vascular exam

A

Inspection and palpation

55
Q

List AND describe the grading scale used to evaluate pulses

A

0Absent
1Weak
2Normal
3Bounding

56
Q

Embolus

A

Travels

57
Q

Thrombus

A

Doesn’t move

58
Q

What are the 5Ps

A

Pain
Pallor
Paresthesia
Pulselessness
Paralysis

59
Q

List AND describe the grading scale used to evaluate edema

A

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

60
Q

What are some subjective questions that relate to the peripheral vascular exam

A

Have you had any recent swelling
Do you have a history of blood clots
Any changes in sensation, numbness, or tingling

61
Q

What assessment techniques are used during the skin exam

A

Inspection, Palpation, inspection

62
Q

What are the 3 steps of the BEDSIDE SKIN exam

A

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

63
Q

What are three meaningful subjective questions that relate to the skin exam

A

History of skin disease
Change in pigmentation/moles
Any new rash or lesions

64
Q

How does the nurse specifically assess skin temperature during the skin exam?

A

Palpates forearms and tibias

65
Q

What 3 findings are being assessed on the forearms and tibias during the BEDSIDE exam

A

Temperature
Texture
Moisture

66
Q

Which 2 findings are being assessed on the upper and lower extremities during the BEDSIDE skin exam

A

Color and intactness

67
Q

Which 2 findings are being assessed on the upper and lower extremities during the BEDSIDE skin exam

A

Color and intactness

68
Q

Describe 3 conditions that put a patient at risk for skin breakdown

A

Wheelchair bound
Paralysis
Coma

69
Q

What 2 findings are being assessed during inspection of the bony prominences during the skin exam

A

Color intactness
Skin breakdown

70
Q

What is the difference between the peripheral vascular exam and the skin exam

A

Circulation
Intactness and abnormalities

71
Q

What are the 6 places we check for Semi-fowlers position

A

Coccyx
Heels
Sacral
Elbow
Scapula
Occipital

72
Q

What 6 places do we check for supine position

A

Heels
Sacrum
Spine
Elbows
Scapula
Occipital

73
Q

What 5 places do we check for lateral position

A

Ankle
Knee
Hip
Scapula
Ear

74
Q

Describe specifically how to assess AND evaluate capillary refill

A

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

NUR 223 (5 decks)

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