Week 3 Skin and Muscle Flashcards
Explain the significance of ABCDE in skin assessment
Asymmetry Border irregularity Color variation Diameter > 6mm Elevation/enlargement
Dark red discolored areas caused by minor trauma that occurs in the older adult
Senile Purpura Purpuric lesions (Caused by blood flowing out of vessels. Red blood cells and blood pigments are deposited into the tissues (extracellular space))
Assessment of dehydration of the skin (test)
Skin turgor and mobility
Pinch skin on anterior chest below clavicle
Mobility = skins ease of rising
Turgor = ability to return to place promptly when released
Assesses hydration status
Mobility is decreased when edema is present
Turgor is poor when client is dehydrated/malnourished
This finding occurs in heart or kidney failure and is graded on a 1+ to 4+ scale
Edema
1+: Mild pitting, slight indentation, no perceptible swelling of the leg
2+: Moderate pitting, indentation subsides rapidly
3+: Deep pitting, indentation remains for a short time, swelling of leg
4+: Very deep pitting, indentation lasts a long time, gross swelling and distortion of leg
Xerosis
Skin that is excessively dry
Seborrhea = oily
Pallor in a dark skinned client
Ashen, grey or dull
Oral mucosa, palpebral conjunctiva (lower, inside of eyelid) and sclera (best)
Lips and nail beds (not most reliable)
Confluent lesions
Lesions that run together (such as urticaria (hives))
Grouped lesions are clustered together.
Annular lesions are circular in nature.
Zosteriform lesions are arranged along a nerve route.
Erythema
Color change of the skin indicating a febrile illness (fever), polycythemia, venous statsis …
Profile Sign
Assess for clubbing of the fingernails. Angles larger than 160° indicate early clubbing which accompanies congenital, chronic and cyanotic heart and respiratory disease
A pressure injury with full thickness skin loss
Stage 3
Stage 1 Non-Blanchable Erythema
Stage 2 Partial Thickness Skin Loss
Stage 3 Full Thickness Skin Loss
Stage 4 Full Thickness Skin/Tissue Loss
Primary lesion seen in psoriasis
PLAQUE: Papules coalesce wider than 1 cm to form a plaque like, disc-shaped lesion. Examples: Psoriasis, lichen planus
Ligament
Fibrous band that lashes bone to bone and prevents undesired movements
Articulation between Femur, Tibia and Patella - largest hinge joint
The Knee
Capable of flexion and extension
Ball and socket joint capable of circumduction
Glenohumeral joint (shoulder joint)
Expected finding of the older adult due to shortening of vertebrae
Postural changes and kyphosis
Disease affecting the bones of the wrist, hip and spine caused by weakening of bone
Osteoporosis
New bone growth occurs slower than bone breakdown
Inflammatory disease that presents in bilateral joints and worse in the morning
Rheumatoid arthritis
Osteoarthritis – may be unilateral and is worse later in the day
Muscle strength testing grade of 5
Grade 5 = full contraction and resistance
Grade 0 = no contraction
audible and palpable crunching or grating over a joint – occurs when bone surfaces in a joint are rough
Crepitus
Active ROM
Active (voluntary) ROM
Have client perform active ROM first, only perform passive ROM if limitation noted
Phalen Test
Assessment of Carpal Tunnel
Ask client to hold hands back to back with wrist bent at 90°
If client has no symptoms after 60 seconds = normal finding
Numbness and tingling = positive Phalen sign indicative of carpal tunnel syndrome
Subluxation
Partial dislocation
Swelling indicates joint irritation due to effusion (excess joint fluid), inflammation or bony enlargement
Dislocation (one or more bones in a joint out of place
Contracture (shortening of a muscle leading to < ROM)
Ankylosis (stiffness/fixation of a joint)
