Week 3 Skin and Muscle

Question 1

Explain the significance of ABCDE in skin assessment

Answer 1

Asymmetry
Border irregularity
Color variation
Diameter > 6mm
Elevation/enlargement

Question 2

Dark red discolored areas caused by minor trauma that occurs in the older adult

Answer 2

Senile Purpura
Purpuric lesions (Caused by blood flowing out of vessels. Red blood cells and blood pigments are deposited into the tissues (extracellular space))​

Question 3

Assessment of dehydration of the skin (test)

Answer 3

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​

Question 4

This finding occurs in heart or kidney failure and is graded on a 1+ to 4+ scale

Answer 4

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

Question 5

Xerosis

Answer 5

Skin that is excessively dry

Seborrhea = oily

Question 6

Pallor in a dark skinned client

Answer 6

Ashen, grey or dull

Oral mucosa, palpebral conjunctiva (lower, inside of eyelid) and sclera (best)​

Lips and nail beds (not most reliable)​

Question 7

Confluent lesions

Answer 7

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.

Question 8

Erythema

Answer 8

Color change of the skin indicating a febrile illness (fever), polycythemia, venous statsis …

Question 9

Profile Sign

Answer 9

Assess for clubbing of the fingernails. Angles larger than 160° indicate early clubbing which accompanies congenital, chronic and cyanotic heart and respiratory disease​

Question 10

A pressure injury with full thickness skin loss

Answer 10

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​

Question 11

Primary lesion seen in psoriasis

Answer 11

PLAQUE: Papules coalesce wider than 1 cm to form a plaque like, disc-shaped lesion. Examples: Psoriasis, lichen planus​

Question 12

Ligament

Answer 12

Fibrous band that lashes bone to bone and prevents undesired movements

Question 13

Articulation between Femur, Tibia and Patella - largest hinge joint

Answer 13

The Knee

Capable of flexion and extension

Question 14

Ball and socket joint capable of circumduction

Answer 14

Glenohumeral joint (shoulder joint)

Question 15

Expected finding of the older adult due to shortening of vertebrae

Answer 15

Postural changes and kyphosis

Question 16

Disease affecting the bones of the wrist, hip and spine caused by weakening of bone

Answer 16

Osteoporosis

New bone growth occurs slower than bone breakdown

Question 17

Inflammatory disease that presents in bilateral joints and worse in the morning

Answer 17

Rheumatoid arthritis

Osteoarthritis – may be unilateral and is worse later in the day​

Question 18

Muscle strength testing grade of 5

Answer 18

Grade 5 = full contraction and resistance

Grade 0 = no contraction

Question 19

audible and palpable crunching or grating over a joint – occurs when bone surfaces in a joint are rough

Answer 19

Crepitus

Question 20

Active ROM

Answer 20

Active (voluntary) ROM

Have client perform active ROM first, only perform passive ROM if limitation noted

Question 21

Phalen Test

Answer 21

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​

Question 22

Subluxation

Answer 22

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)​

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