Skin Assessment - Class 2

Question 1

thorough skin assessment is

Answer 1

paramount

Question 2

what is key

Answer 2

prevention

Question 3

early intervention is

Answer 3

critical

Question 4

what should we identify

Answer 4

threats to skin integrity

Question 5

visual inspection…

Answer 5

alone is not sufficient

Question 6

parts of skin assesment

Answer 6

touch

observation (look with good lighting)

talk/document

smell

listen

Question 7

2 overall assessments

Answer 7

subjective and objective

Question 8

subjective assesment

Answer 8

subjective (RFs)

medical history

medications

nutrition

smoking, drugs, alc use

activity level

Question 9

medical history –> subjective

Answer 9

diabetes

hypertension

renal dz

etc.

Question 10

nutrition –> subjective

Answer 10

obesity/fragility

Question 11

activity level –> subjective

Answer 11

exercise

mobility

ADL

Question 12

objective skin assessment components

Answer 12

skin integrity

ethnicity

sensory status

moisture

atrophic changes

turgor/texture

nail composition and hair quality

edema, color and temp variations

observe skin folds

vascular status

lesions

callus

scar

Question 13

skin integrity

Answer 13

is the skin in tact or does it present with injury

classify stage (if there is a pressure ulcer)

describe –> shape, size, depth, etc.

Question 14

ethnicity

Answer 14

note skin tone and dermatological variants

Question 15

sensory status

Answer 15

intact or altered

light touch –> location –> specific tests and soft tissue status

Question 16

moisture

Answer 16

dry or moist to touch

normal

Question 17

dry –> moisture

Answer 17

xerosis

flaking

scales

fissures

rash

Question 18

wet –> moisture

Answer 18

sweat

weeping edema

incontinence

Question 19

atrophic changes

Answer 19

shiny, hairless extremities

recommend vascular consult

Question 20

turgor/texture

Answer 20

tent the skin on dorsum of hand to test

Question 21

turgor

Answer 21

skin elasticity

normal v. delayed

Question 22

texture

Answer 22

how does the skin feel?

normal, watery, softly pitting, brawny/fibrotic, hard/noncompressible

Question 23

nail composition and hair quality

Answer 23

both are extensions of the skin

Question 24

nails

Answer 24

color

shape

clubbing

thickness

Question 25

hair

Answer 25

distribution hair loss

Question 26

what can color of the nails tell you

Answer 26

pale - anemia half pink and half white - kidney dysfxn yellow - lung dz or nail infection half moons are red - lupus, heart dx, etc.

Question 27

clubbing of the nail

Answer 27

nails are wider chronic low O2

Question 28

weak nails

Answer 28

vitamin B, calcium, iron deficient

Question 29

thick nails

Answer 29

fungal infection

Question 30

vertical ridges on nail

Answer 30

common as we age decrease in vitamins A, B, D, keratin, etc.

Question 31

horizontal ridges on nail

Answer 31

Beau's lines dysfxn of thyroid vitamin deficient injury

Question 32

what is glaborous hair

Answer 32

non hairy regions palms, soles

Question 33

what is non glaborous

Answer 33

hairy regions

Question 34

hirsutism hair

Answer 34

excessive body hair

Question 35

alopecia

Answer 35

hair loss thyroid protein deficiency

Question 36

hair shedding

Answer 36

thyroid dysfxn hormone dysfxns iron deficiencies

Question 37

grey hair

Answer 37

stress or genetic

Question 38

dandruff

Answer 38

sebhorric dermatitis fungus

Question 39

edema

Answer 39

note location pitting or non-pitting

Question 40

color

Answer 40

white, red, blue, yellow, black

Question 41

pigmentation

Answer 41

pallor cyanosis jaundice hyper/hypo

Question 42

temp

Answer 42

normal, cool, warm or hot to touch compare to the other side

Question 43

observe skin folds

Answer 43

breast tissue, abdominal tissue, skin creases

Question 44

what to look for in skin folds

Answer 44

skin breakdown yeast/fungal infections foreign objects

Question 45

callus

Answer 45

indicates area(s) of high pressure or repetitive stress/trauma

Question 46

scar --> normal trophic

Answer 46

normal

Question 47

scar --> hypertrophic

Answer 47

high w/in margins

Question 48

scar --> keloid

Answer 48

high beyond margins

Question 49

scar --> immature

Answer 49

darker/red/raised/move as one piece/immobile/sensitive/insensate

Question 50

scar --> mature

Answer 50

lighter/flat. segmental movement/ mobile/ normal sensation

Question 51

vascular status

Answer 51

look, listen and feel for color changes, doppler, palpate pulses, capillary refill, ABI and rubor of deficiency

Question 52

lesions

Answer 52

rashes, scars, bruising, hemosiderin, nevi-birthmark or mole, etc.

Question 53

document --> lesions

Answer 53

locations describe presentation formulate working clinical dx denote anything unusual or suspicious

Question 54

pulses

Answer 54

femoral popliteal dorsalis pedis post tibial

Question 55

pulse grades

Answer 55

0-4+

Question 56

pulse grade --> 0

Answer 56

no pulse

Question 57

pulse grade --> 1+

Answer 57

barley felt

Question 58

pulse grade --> 2+

Answer 58

diminished

Question 59

pulse grade --> 3+

Answer 59

normal

Question 60

pulse grade --> 4+

Answer 60

bounding

Question 61

assessment of pressure ulcers uses

Answer 61

braden scale

Question 62

braden scale looks for

Answer 62

early identification of pts at risk for forming pressure sores

Question 63

braden scale has

Answer 63

6 subscales

Question 64

subscales of the braden scale

Answer 64

sensory perception skin moisture activity mobility friction and shear nutritional status

Question 65

the lower the braden scale

Answer 65

higher the risk of pressure sore development

Question 66

high risk --> braden score

Answer 66

total score of 6-12

Question 67

moderate risk --> braden score

Answer 67

total score 13-14

Question 68

mild risk --> braden scale

Answer 68

15-18

Question 69

no risk --> braden scale

Answer 69

19-23

Question 70

wagner scale

Answer 70

for diabetic ulcers asses ulcer depth and foot lesions in diabetic feet

Question 71

how often to diabetic foot ulcers occur in those w/ diabetes

Answer 71

15%

Question 72

what doesnt the wagner scale describe

Answer 72

infected or ischemic wounds

Question 73

wagner scale --> grade 1

Answer 73

partial or full thickness ulcer superficial

Question 74

wagner scale --> grade 2

Answer 74

deep ulcer extended to lig, tendon, joint capsule, bone or deep fascia w/o abscess or osteomyelitis

Question 75

wagner scale --> grade 3

Answer 75

deep abscess osteomyelitis or joint sepsis

Question 76

wagner scale --> grade 4

Answer 76

partial foot gangrene

Question 77

wagner scale --> grade 5

Answer 77

whole foot gangrene

Question 78

university of texas wound class system

Answer 78

newer more descriptive v. wagner assesses wounds in the diabetic foot

Question 79

texas --> grade 0

Answer 79

pre/post ulcerative state

Question 80

texas --> grade 1

Answer 80

superficial wound no tendon, capsule, bone involvement

Question 81

texas --> grade 2

Answer 81

wound penetrates to tendon or capsule

Question 82

texas --> grade 3

Answer 82

wound penetrates to bone or joint

Question 83

what does the texas class system include

Answer 83

subsets to categorize infection and ischemia