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NUR 223 > Skin+Peripheral Vascular > Flashcards

Skin+Peripheral Vascular Flashcards

(74 cards)

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1
Q

What is the purpose of the skin and vascular system?

A

Feel all pulses and ensure heart and blood flow is intact

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2
Q

Describe the general purpose of the lymphatic system

A

Maintain fluid balance in the body by collecting excess fluid from tissues and returning it to blood

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3
Q

Pallor

A

Pale

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4
Q

Erythema

A

Red

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5
Q

Cyanosis

A

Blue

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6
Q

Jaundice

A

Yellow

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7
Q

Location of carotid artery

A

Neck

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8
Q

Location of brachial pulse

A

Upper arm

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9
Q

Location of radial pulse

A

Thumb side of lower arm

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10
Q

Location of femoral pulse

A

Upper leg

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11
Q

Location of popliteal pulse

A

Knee

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12
Q

Location of posterior tibial pulse

A

Towards back of ankle

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13
Q

Location of dorsalis pedis pulse

A

Top of foot

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14
Q

Arteries

A

Elastic walled vessels that carry blood from heart through the body

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15
Q

Femoral artery

A

Chief artery of the anterior inner thigh

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16
Q

Veins

A

Tubular branching vessels that carry blood from capillaries to heart

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17
Q

Pulse

A

Regular expansion of an artery caused by ejection of blood into arterial system

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18
Q

Edema

A

Swelling

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19
Q

Embolus

A

Abnormal particle (mass) circulating in the blood

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20
Q

Thrombus

A

Clot of blood formed within a blood vessel and remains attached

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21
Q

Thrombus

A

Clot of blood formed within a blood vessel and remains attached

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22
Q

TED hose

A

Thromoboembolic deterrent hose used to apply compression to a superficial leg vein and prevent the formation of blood clots

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23
Q

SCDs

A

Sequential compression devices used as mechanical prophylaxis in the prevention of the formation of blood clots

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24
Q

Virchow’s Triad

A

3 factors that place a person at risk for the formation of blood clots: blood stasis and hypercoaguability and injury to the vessel wall

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25
Doppler probe
Transducer applied to the skin to assess blood flow and locate arteries
26
Paresthesia
Sensation of prickling, tingling, on skin with no objective cause
27
What are the 5 Ps to assess compromised circulation
Pain Pallor Pulselessness Paresthesia Paralysis
28
What is the largest organ in the body
Skin which is the protective barrier
29
What is included with the skin exam portion of the bedside assessment
Inspection Palpation
30
What is the order of the layers of the skin
Epidermis Dermis Subcutaneous tissue Muscle Bone
31
What are 3 examples of lesions to the skin
Freckles Moles Sores Skintags Insect bites
32
Pressure ulcer
Tissue injury resulting from prolonged pressure on the skin
33
Lesion
Abnormal change in structure of an organ or body part
34
Nevus
Congenital highly pigmented area of skin, flat or raised
35
Lice
Small wingless flat insect, sucks blood, gets in hair
36
Clubbing
Bulbous enlargement of the ends of one or more fingers or toes
37
Pigmentation
Deposition or presence of pigment
38
Striae
Stretch marks
39
Keloid
Thick scar resulting from excessive growth of fibrous tissue
40
Pruritis
Itching sensation on skin
41
Turgor
State of turgidity and rigidity of cells or tissues
42
Necrotic
Death of localized area of tissue
43
Diaphoresis
Profuse perspiration
44
Dehydration
Abnormal depletion of body fluids
45
Texture
Visual or tactile surface characteristics of appearance
46
Dorsal
Relating to or situated near or on the back
47
Ventral
Relating to belly or anterior side
48
Hypothermia
Subnormal temperature of thebody
49
Hyperthermia
Exceptionally high fever
50
Semi fowlers position
Supine position with HOB raised 30-45 degrees
51
High fowlers position
Supine position with HOB raised 90 degrees
52
Lateral position
Side, lying on side
53
What are the steps of the BEDSIDE peripheral vascular exam?
Inspect upper and lower extremities for symmetry of size Palpates for radial pulses Palpates capillary refill Palpates dorsalis pedal pulses Palpates lower extremities for edema
54
What assessment techniques are used during the BEDSIDE peripheral vascular exam
Inspection and palpation
55
List AND describe the grading scale used to evaluate pulses
0Absent 1Weak 2Normal 3Bounding
56
Embolus
Travels
57
Thrombus
Doesn’t move
58
What are the 5Ps
Pain Pallor Paresthesia Pulselessness Paralysis
59
List AND describe the grading scale used to evaluate edema
1/4 mild pitting, slight indentation, no perceptible swelling 2/4: moderate pitting, indentation, subsides rapidly 3/4: deep pitting, indentation remains short time, legs look swollen 4/4: very deep pitting, indentation lasts a long time, legs grossly swollen
60
What are some subjective questions that relate to the peripheral vascular exam
Have you had any recent swelling Do you have a history of blood clots Any changes in sensation, numbness, or tingling
61
What assessment techniques are used during the skin exam
Inspection, Palpation, inspection
62
What are the 3 steps of the BEDSIDE SKIN exam
Inspect upper and lower extremities for color and intactness Palpates upper and lower extremities with light touch for texture, temperature,moisture Inspects skin condition for patient lying in supine position for color and intactness
63
What are three meaningful subjective questions that relate to the skin exam
History of skin disease Change in pigmentation/moles Any new rash or lesions
64
How does the nurse specifically assess skin temperature during the skin exam?
Palpates forearms and tibias
65
What 3 findings are being assessed on the forearms and tibias during the BEDSIDE exam
Temperature Texture Moisture
66
Which 2 findings are being assessed on the upper and lower extremities during the BEDSIDE skin exam
Color and intactness
67
Which 2 findings are being assessed on the upper and lower extremities during the BEDSIDE skin exam
Color and intactness
68
Describe 3 conditions that put a patient at risk for skin breakdown
Wheelchair bound Paralysis Coma
69
What 2 findings are being assessed during inspection of the bony prominences during the skin exam
Color intactness Skin breakdown
70
What is the difference between the peripheral vascular exam and the skin exam
Circulation Intactness and abnormalities
71
What are the 6 places we check for Semi-fowlers position
Coccyx Heels Sacral Elbow Scapula Occipital
72
What 6 places do we check for supine position
Heels Sacrum Spine Elbows Scapula Occipital
73
What 5 places do we check for lateral position
Ankle Knee Hip Scapula Ear
74
Describe specifically how to assess AND evaluate capillary refill
Depress/blanch TIP of nail beds on SAME FINGER ON EACH HAND release and note time for color return Typically refill within a fraction of a second or 2 <2 seconds

NUR 223 (5 decks)

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