Unit 1 Test Flashcards
(226 cards)
1
Q
What does the term Woods Lamp mean?
A
Used when a lesion is suspected fungal infection. Blue-green fluorescence indicates fungal infection.
2
Q
What does the term Mobility (of skin) mean?
A
When palpating skin this term refers to how easily the skin is able to be pinched.
3
Q
What does the term Turgor (of skin) mean?
A
When palpating this term refers to the skin’s elasticity and how quickly it returns to it’s original shape within 30 seconds
4
Q
What does the term Edema mean?
A
Term used to describe fluid retention in tissues, resulting in indentation remaining when palpating with thumbs over ankles/feet.
5
Q
What does the term Tinea Capitus mean?
A
Ringworm of the scalp
6
Q
What does the term Tinea Corporis mean?
A
Ringworm of the body
7
Q
What does the term Hirsutism mean?
A
Term for facial hair on females
8
Q
Whatdoes the term Beau’s lines mean?
A
Term for indents across the nail
9
Q
What does the term late clubbing mean?
A
Greater than 180-degree angle at the nail base. Indicates chronic hypoxia (low oxygen)
10
Q
What does the term spoon nails mean?
A
Concave shape of finger nails indicating iron deficiency anemia.
11
Q
What does the term Paronychia mean?
A
inflammation of the nail bed caused by local infection
12
Q
What does the term capillary refill mean?
A
This assessment is elicited by pressing the nail tip briefly and watching for the color to blanch. Pink tone should return within 2 seconds.
13
Q
What does the term striae mean?
A
Medical term for stretch marks
14
Q
What does the term vitiligo mean?
A
Depigmentation (loss of pigment) of the skin
15
Q
What does the term Nevus mean?
A
Another term for a mole, may be macular or papular
16
Q
What does the term Cherry angioma mean?
A
Small, red, raised spots typically seen with aging.
17
Q
What does the term Paresthesia mean?
A
Abnormal sensations of tingling, pricking or burning
18
Q
What does the term Pruritus mean?
A
Medical term for itching.
19
Q
What does the term Alopecia mean?
A
Partial or complete absence of hair from an area or areas where it normally grows.
20
Q
What does the term MRSA mean?
A
Acronym for Methicillin-resistant Staphylococcus aureus (bacterial resistant, often hospital acquired infection which may affect the skin)
21
Q
What does the term Exacerbate mean?
A
Term used to describe when an activity/substance, etc. is causing a condition to “worse”
22
Q
Dark brown pigment in the hair, nails, skin and iris. Less amounts results in light skin color. More results in darker skin color.
A
Melanin
23
Q
Screening tool used to predict pressure sore risk
A
Braden Scale
24
Q
Term to describe a loss of color, or paleness of the skin.
A
Pallor
25
Blue-tinge visible in white skin especially in perioral, nails and conjunctival areas. Indication of ischemia
Cyanosis
26
Inadequate blood supply to an area of the body
Ischemia
27
Specific type of cyanosis that occurs from cardiopulmonary problems
Central cyanosis (around mouth/oral mucosa)
28
Specific type of cyanosis that occurs from a local problem causing vasoconstriction, decreasing the blood supply to that one area
Peripheral cyanosis (digits/extremities)
29
Yellow skin tones particularly in the sclera, oral mucosa, palms and soles.
Jaundice
30
Roughening and darkening of skin in localized areas particularly the posterior neck suggestive of diabetes.
Acanthosis nigricans
31
Medical term for excessive perspiration
Diaphoresis
32
Skin redness and warmth seen with inflammation, allergies or trauma
Erythema
33
Small, flat, nonpalpable skin color change (any color). Less than 1 cm and have a circumscribed border. (Ex. freckles, flat moles (nevi), petechiae)
Macule
34
Small, flat, nonpalpable skin color change (any color). Greater than 1 cm and may have an irregular border. (Ex. vitiligo, port wine stains and ecchymosis).
Patch
35
Elevated, palpable, solid mass. Circumscribed border. Less than 0.5 cm. (Ex. elevated nevi(moles), warts)
Papule
36
Elevated, palpable, solid mass. May be coalesced papules with an irregular border and a flat top. Greater than 0.5 cm. (Ex. psoriasis)
Plaque
37
Elevated, solid, palpable mass that extends deepter into the dermis than a papule. 0.5 -2 cm and borders are circumscribed. (Ex. Keloid, lipoma)
Nodule
38
Elevated, solid, palpable mass that extends deep into the dermis. Measures greater than 2 cm and borders may be irregular. (Ex. carcinoma/cancerous tumor)
Tumor
39
Elevated, palpable mass with circumscribed borders containing serous fluid. Measures less than 0.5 cm. Small blister
Vesicle
40
Elevated, palpable mass with circumscribed borders containing serous fluid. Measures greater than 0.5 cm. Large blister
Bulla
41
Elevated mass with transient, irregular borders. Size and color vary. No free fluid in a cavity. (Ex. urticaria(hives) and insect bites)
Wheal
42
Pus-filled vesicle or bulla. (Ex. acne, furuncles(boil) and carbuncle(collection of boils)).
Pustule
43
Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis.
Cyst
44
Loss of superficial epidermis that does not extend into the dermis. This would be secondary to a ruptured vesicle, scratch mark, canker sore.
Erosion
45
Skin loss extending past the epidermis, with necrotic tissue loss. Bleeding/scarring are possible. Ex. Stasis ulcer and pressure (aka decubitus) ulcer.
Ulcer
46
Skin mark left after wound/lesion healing that represents replacement by connective tissue of the injured tissue.
Scar (cicatrix)
47
Linear crack in the skin that may extend into the dermis. May be painful. Ex. chapped lips or hands, athlete's foot (tinea pedis).
Fissure
48
Round red or purple macule. Secondary to blood extravasation (leaking) and associated with bleeding tendencies. Less than 2 cm.
Petechia (petechiae)
49
Round or irregular macular lesion that is larger than 2 cm. The color varies and changes. It is secondary to blood extravasation (leaking) and associated with trauma and bleeding tendencies.
Ecchymosis (ecchymoses)
50
Localized collection of blood that creates an elevated area of ecchymosis. Associated with trauma.
Hematoma
51
Papular and round, red or purple lesion found on the trunk or extremities. May blanch with pressure. Normal age related alteration.
Cherry Angioma
52
Red arteriole lesion with a central body and radiating branches. Noted on face, neck, arms and trunk. Rarely below the waist. Lesion blanches with compression of the center. Associated with liver disease.
Spider Angioma
53
Bluish or red lesion with varying shape (spider-like or linear). Found on legs and anterior chest. Does NOT blanch when pressure applied. Secondary to superficial dilation of vessels and capillaries associated with increased venous pressure (varicosities)
Telangiectasis (venous star)
54
Non-blanchable redness of intact skin, usually over bony prominence. Difficult with dark skin tones. Color may just be slightly different as opposed to red.
(Pressure Ulcer Staging)
Stage I (Pressure Ulcer)
55
Partial thickness of dermis is lost. Shallow, open ulcer with red-pink wound bed. No slough is present. MAY ALSO PRESENT AS A BLISTER (INTACT OR RUPTURED).
(Pressure Ulcer Staging)
Stage II (Pressure Ulcer)
56
Epidermis and dermis are lost. Subcutaneous tissue may be exposed. Slough may be present; however depth remains visible
(Pressure Ulcer Staging)
Stage III (Pressure Ulcer)
57
Epidermis, dermis and subcutaneous tissue are lost and bone, tendon or muscle are exposed.
(Pressure Ulcer Staging)
Stage IV (Pressure Ulcer)
58
Yellow, cream or grey colored dead tissue.
Slough
59
Black or dark brown, dead skin tissue.
Eschar
60
Erosion under the wound edges, resulting in a large wound with a small opening.
Undermining
61
Caused by destruction of the fascial planes which results in a narrow passageway. Results in dead space that has the potential for abscess formation.
Tunneling
62
Full-thickness tissue loss; however, the base of the ulcer is covered by slough and/or eschar.
(Pressure Ulcer Staging)
Unstageable
63
Lesions are asymmetrical, have irregular borders, color variations, diameter exceeding 1/4 of an inch, and elevated.
Warning signs of malignant melanoma
64
Lesion configuration in a straight line, as in a scratch or streak.
Linear
65
Lesion configuration of a circular shape (Ex. tinea corporis - ring worm of body)
Annular
66
Lesion configuration where lesions are grouped together. (Ex. herpes simplex)
Clustered
67
Configuration where lesions are individual and distinct. (such as moles (nevi).
Discrete
68
Configuration of lesions that are coin-shaped
Nummular
69
Configuration where smaller lesions run together to form a larger lesion. (Ex. hives (urticaria).
Confluent
70
Parallel ridges running lengthwise on the nail. Normal variation
Longitudinal Ridging
71
Nail bed is half white on the upper half and pink on the distal half. Seen with kidney (renal) disease.
Half-and-half nails
72
Small pits in the nail seen with psoriasis
Pitting
73
Spoon shaped nails. Seen with iron deficiency anemia, endocrine or cardiac disease or trauma).
Koilonychia
74
Local infection/inflammation of the skin just beyond the nail bed.
Paronychia
75
Angle from nail base to skin is greater than 180 degrees. Indication of hypoxia (low oxygen).
Clubbing
76
Assessment that includes collection of subjective data about client's perception of health for all body systems, past health history, family history, and physical exam. Baseline for future assessments. Only needs to be done once within 24 hr of admission
Initial Comprehensive Assessment
77
Assessment that is done after initial assessment. purpose is to do a mini-overview of body systems, reassessment of problems, and look for any changes or new concerns. Done at beginning of each shift.
Ongoing or Partial Assessment
78
Example of Ongoing Assessment
Head to Toe Assessment
79
Assessment to collect data only about a specific healthcare problem. Takes less time. Ask patient about characteristics about the specific problem. Used for reassessment during shift.
Focused or Problem-Oriented Assessment
80
Rapid Assessment used in life-threatening situations, where immediate intervention is needed. Focus on the life sustaining functions: Airway, Breathing and Circulation
Emergency Assessment
81
What should you do before beginning a health assessment?
If possible, review patient's medical record, always keep an open mind and avoid premature judgements of patients. Get all tools and materials you might need for the assessment before the patient gets there.
82
Four major steps of the assessment phase
1. Collection of Subjective Data
2. Collection of Objective Data
3. Validation of Data
4. Documentation of Data
83
What is subjective data?
includes biographical information (name, age, etc.), history of present concerns (symptoms and sensations), personal health history, family history, and lifestyle practices of patient.
84
How do you obtain subjective data?
Can only be elicited and verified by patient
85
What is objective data?
Any information that can be observed by the examiner. Includes vital signs, appearance (skin, posture, dress, hygiene), behavior/mood, and results from lab and diagnostic testing.
86
How do you obtain objective data?
Can be obtained by observing or using exam techniques like inspection, palpation, percussion, and auscultation. Another source is the patient's medical record.
87
What is validating?
The process of confirming or verifying that the subjective and objective data you collected are reliable and accurate.
88
What is the purpose of validating?
It ensures that the assessment process is not ended before all relevant data has been collected and helps to prevent errors in documentation.
89
How do you validate your data?
Recheck your own data and clarify data with patient. Compare your objective findings with your subjective findings.
90
What is the purpose of documentation of assessment data?
the purpose of documentation of assessment data is to promote effective communication among the healthcare team and to facilitate a safe environment for patient care. It helps to identify health problems, formulate health diagnosis, and to further plan.
91
What is the purpose of a health history interview?
establishes rapport and a trusting relationship with the patient, to ensure you get accurate and meaningful information from them. Also, to gather information on the patient's developmental, psychological, physiologic, sociocultural, and spiritual statues.
92
What are the phases of an interview?
1. Pre-introductory Phase
2. Introductory Phase
3. Working Phase
4. Summary and Closing Phase
93
What occurs in the pre-introductory phase?
Practice your interviewing skills and reflect on personal views and feelings. Review the chart if possible, their reason for visit, medical history, and know where to focus questions on. Then prepare the environment, get a safe, quiet, comfortable place that is free of distractions.
94
What occurs in the introductory phase?`
First introduce yourself and your role, then explain the purpose of the interview, type of questions to be asked, time required, try to alleviate any anxiety patient may have, provide comfort, privacy, and confidentiality. Use active listening and start with open ended questions or an opening remark.
95
What occurs in the Working phase?
The nurse obtains subjective data regarding the health history information, observes the patient's cues, interprets and validates information, and collaborates with the client to identify the problems and develop goals.
96
What occurs in the Summarize and Closing Phase?
Summarize with the patient the information you gathered and validate the problems and goals. Identify and discuss possible plans to resolve the problems. Allow the client enough time to express feelings and ask questions afterwards.
97
What is the purpose of Communication Techniques?
To promote an effective and productive interview.
98
Types of Communication Techniques?
Nonverbal & Verbal
99
Nonverbal Communication Techniques
Appearance, demeanor, facial expression, attitude, silence, listening.
100
Example of acceptable appearance.
be professional, neat, wear name tag at all times.
101
Example of acceptable demeanor.
poised, calm, and attentive.
102
Example of acceptable facial expression.
friendly with neutral expression.
103
Example of acceptable attitude.
Nonjudgmental and accepting.
104
Example of acceptable silence.
intermittent silence allows patient time to reflect and organize thoughts.
105
Example of acceptable listening skills.
Good eye contact, open body position, and open mind.
106
Non verbal communication techniques to avoid
Too much or too little eye contact, standing, too many distractions.
107
Verbal Communication Techniques.
Open-ended questions, closed questions, laundry lists, rephrasing, well-placed phrases, inferring, providing information.
108
Purpose of open-ended questions.
encourages descriptions like "how" or "what"
109
Purpose of closed ended questions.
To obtain facts and focus on specific information, good to start with "when" or "did"
110
Purpose of Rephrasing.
Helps clarify information
111
Purpose of Well-placed Phrases
encourages verbalization, "um-hum, yes, etc."
112
Purpose of Inferring
Uses inferences to obtain more specific information. "I notice you..."
113
Purpose of Providing Information
To answer questions and concerns as they arise.
114
What are the geriatric modifications for age-specific interview techniques?
Keep voice down, always face client. Go to quiet setting. Use brief instructions. Speak with caregivers separately. Assist with dressing if needed and reduce position changes as much as possible. Don't talk down to them and ensure trust and privacy.
115
What are the pediatric modifications for age-specific interview techniques?
Always build a rapport with the patient and the parent. Observe any hesitation to answer and note their attitude and tone. Always actively engage child, use play. Use words that the child will understand - consider developmental level. Explain things as you go, always being honest. Encourage questions, make expectations known, offer praises and rewards.
116
What are the age-specific interview techniques for Toddlers and Preschool age?
Parents usually provide information, include child in discussion, observe parent-child interaction. Allow child to remain close to parent. use simple terms and visual aids like their toys. They have an attention span of 5-10 minutes.
117
What are the age-specific interview techniques for School-age and Adolescents?
Allow the child control and choices. Be respectful of views and feelings. used more detailed explanations. ask to speak adolescents alone. be open, honest, and nonjudgmental.
118
What are the components of the Health History?
1. biographical data
2. chief complaint
3. history of present illness/present health status
4. Personal Medical History
5. Family Health History
6. Review of body systems for current health problems
7. Lifestyle and Health Practices
8. Developmental Level
119
What does biographical data include?
Name, sex, age, address: means of identifying patient and source of information.
120
What does Chief Complaint include?
main reason for seeking health care: "What's your major health problem or concern?"
121
What does History of Present Illness/Present Health Status include?
COLDSPA. How long have you had this problem? How did it start? Has it changed in any way? what makes it better or worse?
122
What does Personal Medical History include?
Childhood illness, immunizations, adult illnesses, accidents, surgeries, allergies.
123
What does Family Health History include?
Age of death of parents, illness of relatives: parents, grandparents, aunts/uncles, children.
124
What does Lifestyle and Health Practices include?
Review of the typical day, sleep patterns, eating, use of medications (ALLERGIES), finances, and social activities.
125
What does Developmental Level include?
Assessing their age-specific developmental level: young adult, middlescent, older adult.
126
What are some tools used for Functional Assessment of Older adults?
ADLs- Activities of Daily Living and IADLs- Instrumental Activities of Daily Living.
127
What is assessed with an ADL?
Evaluation of the person's ability to carry out the basic self-care activities of daily living, such as bathing, eating, grooming, and toileting.
128
What is assessed with an IADL?
Evaluation of the person's ability to carry out activities necessary for the well-being of an individual in society, such as household chores (cooking, cleaning, laundry), mobility-related activities (shopping and transportation), and cognitive abilities (money management, using the phone, making decisions affecting basic safety, and social needs).
129
What is mental status?
The level of cognitive and emotional functioning of a patient.
130
What do we look at for assessing ones mental status?
Speech, appearance, and though process.
131
How do we determine Level of Consciousness (LOC)?
Responsiveness to verbal stimulus, light touch, or painful stimulus for if the person is "Alert." If they are oriented to person, place, time, or situation for "orientation"
132
What is considered a normal Level of Consciousness (LOC)?
A&OX4
| Which equates to alert to verbal stimuli, and is oriented to person, place, time, and situation.
133
What are some abnormal mental status findings?
Lethargic, obtunded, stuporous, comatose. Disoriented, confused.
134
What is considered lethargic?
client opens eyes, answers questions, and falls back asleep.
135
What is considered obtunded?
client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment.
136
What is considered stuporous?
Client awakes to vigorous shake or painful stimuli but returns to unresponsive sleep.
137
What is considered comatose?
Client remains unresponsive to all stimuli, eyes stay closed.
138
What are the components of a General Survey?
Overall impression of the patient, includes Assessing posture, gait, body movement, dress, grooming, behavior and affect, hygiene, facial expression, speech, LOC, skin condition and color, physical development and body build, gender and sexual development, and vital signs.
139
What is used to test mental status including cognitive abilities?
Mini-Mental State Examination (MMSE), Saint Louis University Mental Status Examination (SLUMS), and the Confusion Assessment Method (CAM).
140
What are the cognitive abilities assessed?
Orientation, Concentration, Recent & long term memory, Recall, Abstract reasoning, Judgment, and Visual perceptual & constructional ability.
141
How do you prepare the environment prior to a physical exam?
Make sure the room is warm, comfortable, and private (pull curtains). Make sure the area is distraction free and has good lighting (sunlight if possible). Have firm exam table/bed, adjusted to proper height, and have a bedside table/tray for equipment.
142
How do you prepare Self and Patient for a physical exam?
Assess your anxieties and biases. Build a rapport with the patient. Explain the purpose and describe what will be done throughout the exam. Respect patients wishes. Least intrusive to most. If you are right handed, assess on right side of bed.
143
What needs of the patient must be met during exam?
priority of patient, age and development, mood and comfort level, may need to defer parts of history or exam as needed.
144
What safety measures should be used during exam?
1. Wash hands and clean stethoscope
2. ID patient/ask allergies BEFORE starting
3. Raise bed during exam, lower after.
4. Rail down on your side, opposite side up.
5. Use clean equipment
6. Remove equipment when finished
7. Wash hands & clean stethoscope, again, after exam.
145
What are some modifications that may be required during a physical examination of pediatric patients?
Child may become uncooperative or irritable, so order of assessment may vary. May not be able to do the complete assessment and may have to return later to finish. Do the most important things first, prioritize. General inspection is done first, heart and lungs. intrusive and invasive activities last. Incorporate play!
146
What are some modifications that may be required during a physical exam of geriatric patients?
You will need to assess functional status. Exam may take longer. Speak clearly and at a moderate pace. Remember, the patient is the primary source of information, even if there is family members present.
147
What are some physical changes that occur with aging?
skin thinning & losing integrity, hair thinning & loss, etc.
148
What are some functional changes that occur with aging?
Hearing loss, vision loss, decreased mobility, memory loss, cognitive ability decreasing, etc.
149
How do you determine patients level of pain?
Pain is whatever the patient says it is.
150
What kind of data is pain considered?
Subjective data
151
What is pain assessed as?
The fifth vital sign.
152
What are some barriers to pain assessment?
Age and culture. Patient's beliefs, physical conditions, Healthcare provider's beliefs.
153
What are some physiologic responses to pain?
Anxiety, fear, decreased cognitive functioning, dilated pupils, cries/moans, frowns, facial grimacing, posture - huddled. decreased gastric/intestinal motility, urinary retention, hyperglycemia, muscle spasm. Patients vital signs may indicate pain (but are not reliable) increased heart rate, respiratory rate, and blood pressure.
154
What are some Pain Assessment Tools?
Numeric Rating scale: 0-10 pain intensity
Universal Pain Assessment Tool: uses faces to describe intensity of pain for kids and older adults with cognitive problems.
FLACC Behavioral Scale: used for preverbal children to assess level of pain
155
What is done during inspection?
Inspection starts immediately when walking in the room. You look, listen, and smell. May need additional equipment to do so. (otoscope for ears). Observe color, size, location, texture, symmetry, odors, and sounds.
156
What is done during palpation?
Assess texture, temperature, size, moisture, motion, consistency, shape, tenderness, and strength. Do light palpation before deep and palpate tender areas last.
157
What are the types of palpation?
Light, Moderate, Deep, and Bimanual.
158
What is considered light palpation?
< 1 cm using finger pads of dominant hand.
159
When is light palpation used?
For assessing pulses, texture, temperature, and moisture.
160
What is considered moderate palpation?
1-2 cm with dominant hand, circular
161
When is moderate palpation used?
For assessing easily palpable internal organs and masses.
162
What is considered deep palpation?
2.5-5 cm with dominant hand on skin and non dominant hand on top of hand.
163
When is deep palpation used?
For assessing very deep organs.
164
What is considered bimanual palpation?
Having one hand on each side of the body part or organ.
165
When is bimanual palpation used?
For assessing breasts and deep abdominal organs.
166
What are your finger pads used for assessing?
pulses, texture, size, consistency, shape.
167
What is the ulnar/palmar surface of your hand used for assessing?
Vibrations, thrills, fremitus.
168
What is the dorsal surface of your hand used for assessing?
temperature
169
What is done during percussion?
tapping on a body part to help identify location, size, and shape of organs.
170
What causes a different sound in percussion?
density
171
What are the types of percussion?
Direct percussion, Indirect percussion, and blunt.
172
What is the purpose of direct percussion?
Detects tenderness or pain
173
What is the purpose of indirect percussion?
elicits sounds
174
What is the purpose of Blunt percussion?
Detects tenderness of organs.
175
What are the types of percussion notes?
Resonance, Tympany, Dullness, and Flatness
176
What does Resonance sound like?
Hollow.
177
Where would you normally hear Resonance?
It's heard over part air and part solid. Ex. normal lung sounds.
178
What does tympany sound like?
Drum-like
179
Where would you normally hear Tympany?
It's heard over air. Ex. air in the bowel.
180
What does Dullness sound like?
Thud-like
181
Where would you normally hear Dullness?
It's heard over more solid tissue. Ex. organs
182
What does Flatness sound like?
Flat
183
Where would you normally hear Flatness?
It's heard over very dense tissue. Ex. Muscle or Bone.
184
What is done during auscultation?
Listening to heart, vessel, lung and bowel sounds with a stethoscope.
185
What is the diaphragm (flat, large) of the stethoscope used for?
To listen for high pitched normal sounds and lung and bowel sounds. (press firmly)
186
What is the bell (smaller side) of the stethoscope used for?
To listen for low pitched abnormal heart sounds and bruits (press lightly)
187
What is important to remember during auscultation?
Place stethoscope directly onto skin, not over the clothes or gown.
188
What is the proper order of Physical Exam Techniques?
inspect - palpate - percuss - auscultate.
| EXCEPT in abdominal exam, then you inspect - auscultate - percuss - palpate.
189
What are the basic guidelines for assessment?
1st perform general survey. Respect privacy. Maintain Patient comfort. Communicate with patient. Ask about "abnormal or unusual findings" Follow a planned order (head to toe). Compare right to left. Assess both structure and function. Integrate teaching. Allow time for patient questions.
190
Why do we need to validate information?
To confirm or verify subjective and objective data are reliable and accurate.
191
What data requires validation?
any discrepancies in between subjective and objective data, any abnormal or inconsistent findings, anytime there is missing information.
192
What are some methods of validation?
Recheck the data through repeat assessment, clarify by asking questions, verify with another HCP.
193
What is the purpose of documenting data?
To promote effective communication among health team members and to facilitate safe and efficient client care.
194
What are the guidelines of documentation?
Confidentiality, be legible and neat, write in permanent ink, correct grammar & spelling. Use phrases. Record findings, not how obtained. Document objectively, not opinions. Record patient's understandings & perceptions. Avoid "normal." Record complete info & details. Suport subjective data with your observations. Document using nursing process.
195
What is the recommended way of documenting notes?
PIE Notes
196
What does PIE stand for in documentation?
P- problem
I- interventions
E- evaluate
197
What do you document for the P of PIE notes?
Problem - fully describe the abnormal or risk
198
What do you document for the I of PIE notes?
Interventions- what you do for the patient
199
What do you document for the E of PIE notes?
Evaluate - did your interventions work?
200
What does the mnemonic COLDSPA stand for?
Character - What does it feel like?
Onset- What were you doing when it started?
Location- Where is the pain located?
Duration- How long has this been going on?
Severity- Pain Scale 0-10
Pattern- Consistent or intermittent?
Associated Factors- Any additional signs or symptoms?
201
What is the largest organ of the body?
The Skin
202
What is the most common type of cancer?
Melanoma
203
What are considered abnormal assessment findings of the skin?
cyanosis, jaundice, pallor, erythema, and acanthosis nigricans.
204
What are common "normal" variations of the skin?
Freckles, moles, vitiligo, straie, scars.
| Darker skinned clients- lighter palms, soles, nail beds, lips. Mongolian spots. freckled nail beds & sclera.
205
What are some normal geriatric lesions common with aging?
Venous Lakes, Skin tags, cherry angiomas, seborrheic keratosis, senile purpura, and lentigines.
206
What are venous lakes?
dark blue papule on sun-exposed surfaces.
207
What are skin tags?
Fleshy outgrowth, same color as skin, usually where there are skin folds.
208
What are seborrheic keratosis?
Benign skin growths, slightly raised, tan to black in color. warty appearance.
209
What are senile purpura?
blue/black patches caused by fragile blood vessels that rupture with minimal trauma.
210
What are lentigines?
brown, patchy areas on skin.
211
What are normal findings when palpating skin?
smooth, soft warm. Moist to dry. Pinches easily and returns immediately to original position. No swelling, pitting, or edema.
212
What are some deviations from normal skin findings during palpation?
rough, thick, dry, scaly. Extremely cool or warm, wet, oily. 30 seconds or longer to return to original position when pinched. skin swollen, may indent with pressure.
213
What are some abnormal findings with hair assessment?
dry, brittle,alopecia, lice.
214
What are some normal variations of hair due to aging?
alopecia, thinning of hair, dry, brittle. amount of hair on extremities may be reduced.
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What are some normal findings with nail assessment?
nail grooming, cleanliness, pink in color, capillary refill <3 seconds.
216
What are normal variations in skin, hair, & nail assessment with different ethnicities?
Dark skinned ethnicities tend to have thicker nails. Individuals of African descent may have dry scalps and fragile hair. Cyanosis, erythema, jaundice are more difficult to notice.
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What are normal variations in skin, hair, & nail assessment with aging?
Transparent, pale, dry skin. Hyper pigmented areas. Wrinkling & tenting of skin. Thinning, graying head & body hair. In women, may have facial hair Older adults tend to have thick, yellow, brittle nails.
218
What do you look for with pediatric patients during the skin, hair, and nails assessment?
signs of abuse/neglect. rashes. ecchymoses in varying stages of healing. injuries incongruent with story. pattern/shape of wounds.
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What are normal variations in skin, hair, and nails assessment with pediatric patients?
Skin is lighter shade then parents. oiliness, acne, and lesions in teens. Portwine stains, hemangiomas, café-au-lait spots.
220
What do you document for skin, hair, and nails?
You must document both normal and abnormal findings.
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What is important to document for incisions and wounds?
size and shape (length x width x depth, tunneling? undermining?), location, color, approximated or open. sutures, staples or steri-strips if present. drainage, odor, crusting.
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What is the mnemonic ABCDE used to assess for?
Characteristics of skin cancer,
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What does the mnemonic ABCDE stand for?
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Asymmetry- does it look the same throughout
Border- Smooth or uneven?
Color- all one color? what color is it?
Diameter- how big around is it?
Evolving- Has it changed?
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What are the types of skin cancer?
1. Basal Cell- most common, pearly, depressed center.
2. Squamous cell- scaling, crusting
3. Malignant melanoma- blue, black. most invasive
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What are some risk factors of skin cancer?
Sun exposure, tanning beds, family history of melanoma, HPV, alcohol intake, and age.
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What can you teach to reduce skin cancer?
Reduce sun exposure. always use sunscreen, avoid sunburn. wear long sleeve shirts when exposed for long periods to the sun. Examine skin or get annual screenings.
