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PA-Systemic Assess.
skin and circulation
| Question | Answer |
|---|---|
| Assessment of Skin and Circulation | both may occur as a system of its own, or in conjunction with other body systems |
| Skin Assessment | 1. choose to assess the entire skin surface at one time 2. Assess skin as a part of each body system |
| Skin Assessment Techniques: | Inspection and Palpation |
| Assessment of Skin and Circulation | both may occur as a system of its own, or in conjunction with other body systems |
| Skin Assessment | 1. choose to assess the entire skin surface at one time 2. Assess skin as a part of each body system |
| Skin Assessment Techniques: | Inspection and Palpation |
| Inspect and Palpate the skin for: | 1. color 7. Thickness 2.temp 8. Edema 3. moisture 9. Mobility/Turgo 4. Texture 5. vascularity or bruising 6. lesions |
| Color of skin: things you will look for | e. Jaundic- yellowing of the skin due to an increas in bilirubin *esp in sclera, hard palate, posterior of tongue, and skin (babies= all over) |
| Inspection and Palpation of the skin: best assessed areas for color | areas of least pigmentation; Start from head to toe (change color first) |
| Inspection and Palpation of the skin: Temp. (Hyperthermia) | could be a temp. above 100.4 *S/S= |
| Inspection and Palpation of the skin: Areas of least pigmentation assessed first | Sclera(normally white) Conjunctiva(normally pink) Nail beds lips buccal mucosa tongue palms soles |
| Color of skin: things you will look for | a. General pigmentation b. Pallor- absence of color; best in the nailbeds, lips, mucous membranes, & conjunctiva c. Erythema- areas of injection may appear reddened d. Cyanosis- caused by decreased oxygenation of blood; esp. skin, nailbeds, mucous mem |
| Color of skin: things you will look for | e. Jaundic- yellowing of the skin due to an increas in bilirubin *esp in sclera, hard palate, posterior of tongue, and skin (babies= all over) |
| Inspection and Palpation of the skin: Temp. | Normally skin is warm; excessive coolness or warmth indicates a deviation from normal |
| Inspection and Palpation of the skin: Temp. (Hyperthermia) | A core body temperature much higher than normal, that is, above 37.2° C (99° F). 2. Therapeutic raising of the body temperature to 42°-45° C (107.6°-113.0° F). Also called hyperpyrexia. |
| Inspection and Palpation of the skin: Temp. (Hypothermia) | A condition in which core body temperature is reduced to 32º C (89º F) or lower, usually caused by prolonged exposure to cold |
| Inspection and Palpation of the skin:Tugor and Mobility | Skin tugor is an indicaiton of hydration status; assessed by pinching up the skin and releasing it (skin elasticity) *snap back in 3 sec. *best assessed sternum and forehead: beneath the clavicle for the older adult |
| Inspection and Palpation of the skin: Moisture (diaphoresis) | profuse persiration from increased metabolic rate |
| Inspection and Palpation of the skin: Moisture (dehydration) | look at mucous membranes; the tugor of the skin when pinched will stay up for a lot longer then 3 sec |
| Inspection and Palpation of the skin:Texture | skin should be smooth,soft, flexible, and firm, and with an even surface |
| Inspection and palpation of the skin: Texture irregularity examples | a. Hyperthroidism = results in smoother, velvety skin (access oil collection) b. Hypothroidism= results in rough, dry, and flaky skin |
| Inspection and palpation of the skin: Thinkness | epidermis normally is uniformly thin over most of the body |
| Inspection and palpation of the skin: Thinkness (increased thickness areas) | eczema or calluses |
| Inspection and palpation of the skin: Thinkness (decreased thinness areas) | Arterial insufficiency will result in very thin, shiny, easily breaks, taut skin w/a loss of hair growth |
| Inspection and palpation of the skin:Edema | fluid accumulating in the intracellular spaces that is abnormal most often in the extremeites |
| Types of Edema: Dependent | found in areas of dependence such as feet in erect, ankles, sacrum in bedfast client, or back of knees, back, etc |
| Types of Edema: Peripheral | Starts in feet then progresses to hands and sometimes even the face |
| Types of Edema: Pitting | press finger into edematous area for 2-3 sec and note depth of indentation (make finger marks in the skin) |
| Grades of Pitting Edema: 1+ | slight pit, normal contour |
| Grades of pitting Edema: 2+ | deeper pit, faily normal contour |
| Grades of pitting Edema:3+ | puffy, apperance of deeper pit |
| Grades of pitting Edema: 4+ | Extremely deep pit, def. swollern and loss of contour |
| True of False; you may use a measuring tape and compare sizes of both extremities if edema is present? | True. |
| Types of Edema: Generalized edema(anasarca) | Massive edema *Ex: edema associated w/renal disease (fluid retention con't over an extended period of time) |
| Types of Edema: Pulmonary | fluid rention in the lungs due to imbalanced capillary dynamics |
| How would we examine pulmonary edema? Auscultate or palpate? | Aucultate |
| Types of Edema: cerebral | fluid w/in the brain |
| How would we examine cerebral edema? | See through examination of the eyes |
| Inspection and Palpation of the skin: Lesions | physical changes in the skin caused by a disease process; rarley specific to a disease entity |
| Abnormal characteristics of lesions: ABCDE | A: assymmetry B: Border irregularity (color; does it border the lesion or leak over into skin) C: color D: diameter > 6 cm E: Elevation and Enlargement |
| Lesions should be described in detailed | esp if it is isolated and elevated |
| Lesions should be described in terms of: | color, location, size, tenderness, discharge, crustation, and type of surface |
| Inspection and Palpation: Vascularity and Bruising | Varicose Veins |
| "Primary Skin Lesions" -->Macule | is a change in the color of the skin. It is flat, if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. A macule greater than 1 cm. may be referred to as a patch. |
| "Primary Skin Lesions" --> Papule | is a solid raised lesion that has distinct borders and is less than 1 cm in diameter. Papules may have a variety of shapes in profile (domed, flat-topped, umbilicated) and may be associated with secondary features such as crusts or scales. |
| "Primary Skin Lesions" --> plaque | is a solid, raised, flat-topped lesion greater than 1 cm. in diameter. It is analogous to the geological formation, the plateau. |
| "Primary Skin Lesions" --> nodule | is a raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or subcutaneous tissue |
| "Primary Skin Lesions" --> wheal | is an area of edema in the upper epidermis. |
| "Primary Skin Lesions" --> tumor | a solid mass of the skin or subcutaneous tissue; it is larger than a nodule. (Please bear in mind this definition does not at all mean that the lesion is a neoplasm.) |
| "Primary Skin Lesions" --> vesile | raised lesions less than 1 cm. in diameter that are filled with clear fluid. |
| "Primary Skin Lesions" --> bulla | circumscribed fluid-filled lesions that are greater than 1 cm. in diameter. |
| "Primary Skin Lesions" --> pustule | circumscribed elevated lesions that contain pus. They are most commonly infected (as in folliculitis) but may be sterile (as in pustular psoriasis) |
| primary skin lesions--> patch | macules that are larger than 1 cm |
| primary skin lesions--> urticaria | hives; wheals coalesce to form extensive reaction,intensley prutitic |
| primary skin lesions-->cyst | encapsulated fluid-filled cavity in dermis or subcutaneous layer,tensely elevated skin |
Created by:
ectolle
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