Chapter 30 Integumentary and Peripheral Vascular Systems

Question 0

What type of tool/scale do you use to assess risk of pressure ulcers?

Answer 0

Braden scale

Question 1

Should assessing the integumentary and peripheral systems been done together?

Answer 1

Yes

Question 2

Examples of questions to ask when reviewing two systems are:

Answer 2

Have you notice changes in skin color?
Do you have a rash?
Is skin excessively dry or oily?
Moles or lesions?

Question 3

The description of pallor and indication are:

Answer 3

Loss of color (face, conjunctive, nail beds, palms)

Anemia or lack of blood flow

Question 4

The description of cyanosis and indication are:

Answer 4

Bluish (nail beds, lips, mouth skin)

Hypoxia or impaired venous return.

Question 5

The description of jaundice and indication are:

Answer 5

Yellow to orange (skin, sclera, mucous membrane)

Liverdysfunction, red blood cell destruction.

Question 6

The description of erythema and indication are:

Answer 6

Redness (face trauma, and pressure sore areas)

Inflammation, localized vasodilation

Question 7

What does brown pigmentation changes indicate?

Answer 7

Venous insufficiency.

Question 8

What does shiny and translucent skin without hair on toes and foot indicate?

Answer 8

Arterial insufficiency.

Question 9

When palpating the peripheral pulses, what two things should you be looking?

Answer 9

Strength (amplitude) and equality (symmetry)

Question 10

Strength amplitude should be _________ from beat to beat.

Answer 10

Same

Question 11

Grade strength for peripheral pulse is:

Answer 11

0 absent, unable to palpate
1+ diminished, weaker than expected 
2+ brisk, expected 
3+ increased
4+ full volume, bounding

Question 12

Palpate pulse sites bilaterally to make comparisons with the exception of what area?

Answer 12

Carotid arteries

Question 13

Name locations of seven pulses:

Answer 13

Carotid 
Radial 
Brachial
Femoral
Popliteal (behind knee)
Dorsalis pedis
Posterior tibial (behind and below the medial malleolus of the ankles)

Question 14

What should you inspect the peripheral veins for?

Answer 14

Varicosities, redness, swelling.

Question 15

What is edema?

Answer 15

Fluid in tissues causing swollen, tight and shiny skin surface.

Question 16

How should Edema be assessed?

Answer 16

Discoloration
Location
Tenderness

Measure extremities circumference of swollen body area and compare both sides.

Question 17

Lesions should be examined for what?

Answer 17

Size
Color
Shape
Consistency
Elevation 
Location 
Distribution 
Configuration 
Tenderness
Fluid and drainage.

Question 18

Primary lesions arise from what type of skin tissue?

Answer 18

Healthy skin tissue.

Question 19

What is a macule lesion?

Answer 19

Nonpalpable, skin color change, smaller than 1 cm

Ex. Freckles

Question 20

What is a papule lesion?

Answer 20

Palpable, circumscribed, smaller than 1 cm

Ex. Elevated nevus

Question 21

What is a nodule/tumor?

Answer 21

Palpable, circumscribed, deep, firm, 1 to 2.

Ex. Wart

Question 22

What is a vesicle?

Answer 22

Serous fluid-filled, smaller than 1 cm

Ex. Blister, herpes simplex, varicella

Question 23

What is a pustule?

Answer 23

Pus-filled

Ex. Acne

Question 24

What is a tumor?

Answer 24

Solid mass, deep, larger than 1 to 2 cm. Ex. Epithelioma

Question 25

What is a wheal?

Answer 25

Palpable, irregular borders, edematous Ex. Insect bite

Question 26

What does secondary lesions result from?

Answer 26

A change in a primary lesion.

Question 27

Name the five secondary lesions.

Answer 27

``` Erosion Crust Scale Fissure Ulcer ```

Question 28

Name the seven primary lesions.

Answer 28

``` Macule Papule Nodule Vesicle Pustule Tumor Wheal ```

Question 29

What is an erosion?

Answer 29

Lost epidermis, moist surface, no bleeding Ex. Raptured vesicle

Question 30

What is crust?

Answer 30

Dried blood, serum or pus Ex. Scab

Question 31

What is a fissure?

Answer 31

Linear crack Ex. Tinea pedis

Question 32

What is an ulcer?

Answer 32

Loss of epidermis and dermis with possible bleeding, scarring. Ex. Venous stasis ulcer, pressure ulcer.

Question 33

Examples of skin lesions for children are:

Answer 33

Diaper dermatitis Intertrigo Impetigo Atopic dermatitis (eczema)

Question 34

Examples of skin lesions for adults are:

Answer 34

Primary contact dermatitis Tinea pedis (ringworm of the foot) Psoriasis Labial herpes simplex

Question 35

Examples of skin lesions for older adults are:

Answer 35

Lentigines (liver spots) Seborrheic keratosis Arochordons (skin tags) Sebaceous hyperplasia

Question 36

What do vascular lesions result from?

Answer 36

Aging changes or blood-vessel damage in or near the skin.

Question 37

What are the six vascular lesions?

Answer 37

``` Spider angioma Cherry angioma Spider vein Petechia/purpura Ecchymosis Hematoma ```

Question 38

What is spider angioma?

Answer 38

Red center with radiating red legs, up to 2 cm. possibly raised.

Question 39

What is cherry angioma?

Answer 39

Red 1 to 3 cm, round, possibly raised

Question 40

What is a spider vein?

Answer 40

Bluish, spider-shaped or linear up to several inches in size.

Question 41

What is petechia/purpura?

Answer 41

Deep reddish purple, flat, petechiae 1 to 3 mm, purpura larger than 3 mm

Question 42

What is ecchymosis?

Answer 42

Purple fading to green or yellow over time, variable in size, flat

Question 43

What is a hematoma?

Answer 43

Raised ecchymosis

Question 44

What are expected changes in the peripheral vascular system with age?

Answer 44

Thicker more rigid peripheral blood vessel walls with a narrowed lumen leading to poor peripheral circulation Higher systolic blood pressure.