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NSG 316 TOPIC 1-5 > TOPIC 4 KEY TERMS > Flashcards

TOPIC 4 KEY TERMS Flashcards

1
Q

skin turgor

A

Skin Turgor is the skin’s ability to return to place promptly when released. This reflects the elasticity of the skin.

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2
Q

poor turgor

A

Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or “tents” and stands by itself.

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3
Q

Good skin turgor

A

Good skin turgor reflects adequate hydration.

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4
Q

ABCDE

A

asymmetry, border, color, diameter, evolving

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5
Q

Asymmetry

A

not regularly round or oval, two halves of lesion do not look the same)

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6
Q

Border irregularity

A

notching, scalloping, ragged edges, poorly defined margins)

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7
Q

Color variation

A

areas of brown tan, black, blue, red, white, or combination)

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8
Q

Diameter

A

greater than 6mm (the size of a pencil eraser), although early melanomas may be diagnosed at a smaller size.

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9
Q

Procedure for assessing nails

A

Observe the shape and contour (smooth), uniform-curved or flat? Nail looks consistent? Color?

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10
Q

normal findings of nails

A

View the index finger at its profile and note the angle of the nail base; it should be about 160 degrees. The nail base is firm to palpation. Curved nails are a variation of normal with a convex profile. They may look like clubbed nails, but notice that the angle between nail base and nail is normal (i.e., 160 degrees or less).

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11
Q

abnormal finding of nails

A

Clubbing: often occurs with congenital cyanotic heart disease, lung cancer, and pulmonary diseases.

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12
Q

Capillary Refill

A

Þ With the index or middle fingertip at heart level, depress the nail edge at least 5 seconds to blanch and then release, noting the return of color. Normally: color return is instant or at least within a few seconds in a cold environment. This indicates the status of the peripheral circulation. A healthy color return takes 1 or 2 seconds. Abnormal: Sluggish color return takes longer than 1 or 2 seconds. Cyanotic nail beds or sluggish color return: consider cardiovascular or respiratory dysfunction, septic shock.

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13
Q

Lesions: if any are present, note

A

· Color
· Elevation (flat, raised, or pedunculated)
· Pattern or shape: the grouping or distinctness of each lesion (annular, grouped, confluent, linear)
· Size (in centimeters): use a ruler to measure
· Location and distribution on body: is it generalized or localized to area of specific irritant; around jewelry, watchband, eyes?
· Any exudate: note color and odor

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14
Q

to detect fluorescing lesions use…

A

Use a Wood’s light (ultraviolet light filtered through special glass)

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15
Q

Edema

A

fluid accumulation in the interstitial spaces.

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16
Q

Scale to grade pitting:

A
  • 1+ mild, slight indentation, no perceptible swelling
  • 2+ moderate, indentation subsides rapidly
  • 3+ deep, indentation remains for short time, appears swollen
  • 4+ very deep, indentation last long time, appears very swollen
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17
Q

Primary lesion

A

when a lesion develops on previously unaltered skin

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18
Q

Macule

A

solely a color change; flat and circumscribed, of less than 1 cm

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19
Q

Papule

A

something you can feel (solid, elevated, circumscribed, less than 1 cm diameter)

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20
Q

Patch

A

macules larger than 1 cm

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21
Q

Plaque

A

coalesce to form surface elevation wider than 1 cm. A plateaulike, disk-shaped lesion

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22
Q

Nodule

A

Solid, elevated, hard or soft, larger than 1cm, may extend deeper into the dermis than papule

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23
Q

Wheal

A

Superficial, raised, transient, and erythematous; slightly irregular shape from edema (fluid held diffusely in the tissues)

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24
Q

Tumor

A

Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant

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25
Q

Urticaria

A

Wheal coalesce to form extensive reaction, intensely pruritic

26
Q

Vesicle

A

Elevated cavity containing free fluid, up to 1 cm; a “blister.” Clear serum flows if wall is ruptured.

27
Q

Bulla

A

Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; thin-walled and ruptures easily.

28
Q

Cyst

A

Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin.

29
Q

Pustule

A

Turbid fluid (pus) in the cavity. Circumscribed and elevated

30
Q

· Pigmented nevi (moles)

A

Papule

31
Q

· Freckles

A

Macule

32
Q

Xanthoma

A

Nodule

33
Q

· Mosquito bite

A

Wheal

34
Q

· Chicken Pox

A

Vesicle

35
Q

Crust

A

The thickened, dried out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on fluid ingredients (blood, serum, pus)

36
Q

Scale

A

Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells

37
Q

Fissure

A

Linear crack with abrupt edges; extends into dermis; dry or moist.

38
Q

Erosion

A

Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; health without scare because erosion does not extend into dermis

39
Q

Ulcer

A

Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals

40
Q

Excoriation

A

Self-inflicted abrasion; superficial; sometimes crusted; scratched from intense itching.

41
Q

Scar

A

After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic.

42
Q

Atrophic Scar

A

The resulting skin level is depressed with loss of tissue; a thinning of epidermis

43
Q

Lichenification

A

Prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of loss (or lichen)

44
Q

Keloid

A

A benign excess of scar tissue beyond sited of original injury: surgery, acne, ear piercing, tattoos, infections, burns. Looks smooth, rubbery, shiny and “clawlike”; feels smooth and firm. Found in ear lobes, back of neck, scalp. Chest, and back; may occur months to years after initial trauma. Most common ages are 10-30 years; higher incidences in blacks, Hispanics and Asians.

45
Q

Petechiae

A

Tiny punctate hemorrhages, 1 to 3 mm, round and discrete; dark red, purple, or brown in color. Caused by bleeding from superficial capillaries; will not blanch. May indicate abnormal clotting factors. In dark-skinned people petechiae are best visualized in the areas of lighter melanization

46
Q

Purpura

A

Þ Confluent and extensive patch of petechiae and ecchymoses; >3 mm, flat, red to purple, macular hemorrhage. Seen in generalized disorders such as thrombocytopenia and scurvy. Also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis.

47
Q

Ecchymosis (bruise)

A

Þ - A purplish patch resulting from extravasation of blood into the skin, >3 mm in diameter. A mechanical injury (e.g., a blow) results in hemorrhage into tissues. Skin is intact.

48
Q

Angioma - Spider or Star Angioma

A

A fiery red, star-shaped marking with a solid circular center. Capillary radiations extend from the central arterial body. With pressure, note a central pulsating body and blanching of extended legs. Develops on face, neck, or chest; may be associated with pregnancy, chronic liver disease, or estrogen therapy or may be normal.

49
Q

Seborrhea

A

oily

50
Q

xerosis

A

dry

51
Q

alopecia

A

significant hair loss

52
Q

· Hirsutism

A

shaggy or excessive hair

53
Q

pallor

A

pale/white; the red-pink tones from the oxygenated hemoglobin in the blood are lost

54
Q

cyanosis

A

blueish mottled color from decreased perfusion; the tissues have high levels of deoxygenated blood

55
Q

· Erythema

A

red; intense redness of the skin is from excess blood (hyperemia) in the dilated superficial capillaries

56
Q

jaundice

A

A yellowish skin color indicates rising amounts of bilirubin in the blood

57
Q

brown-tan

A

bronzed appearance; an “eternal tan” most apparent around nipples, perineum, genitalia and pressure points (inner thighs, buttocks, elbow, axillae)

58
Q

stage I pressure ulcer

A

Non-Blanchable Erythema: intact skin, red, unbroken, localized redness, lighter skin-does not blanch, darker skin remains darker-does not blanch

59
Q

stage II pressure ulcer

A

partial-Thickness Skin Loss: Partial thickness erosion, loss of epidermis, shallow abrasion or open blister looking, red-pink wound bed

60
Q

Stage III pressure ulcer

A

· Full-thickness Skin loss: full thickness extending into SQ, crater like, fat may be visible

61
Q

stage IV pressure ulcer

A

Full-thickness skin/tissue loss: full thickness, all layers to supporting structures, muscle, tendon, bone,

62
Q

stages of bruising

A

(1) red-blue or purple immediately after or within 24 hours of trauma and generally progresses to
(2) blue to purple
(3) blue-green
(4) yellow
(5) brown to disappearing.

NSG 316 TOPIC 1-5 (13 decks)

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