Nurs 125 Quiz 2
Sunblock - ANS deflect Uv rays from absorption
Sunscreens - ANS absorb harmful UV rays
general skin assessment - ANS includes color, texture, moisture, turgor, and temperature
Primary lesions - ANS lesions arising from previously normal skin including maculae, papules,
nodules, tumours, polyps, wheals, vesicles, cysts, pustules and abscesses
Secondary lesions - ANS results following primary skin lesions (scar tissue, crusts from dried
burns, etc.)
Vitiligo - ANS loss of pigment in areas of the skin
Unexpected color changes in skin - ANS flushing, erythema (redness), cyanosis (bluish
discolouration), pallor (paleness), rubor (dependant redness), brawny (dark leathery
appearance) and jaundice (yellow discolouration of skin and sclera)
uremic frost - ANS a whitish coating caused by urea and nitrogen skin excretion in the presence
of severe and prolonged kidney failure
Common benign lesions - ANS freckles, birthmarks, skin tags, moles, cherry angiomas
Lesion primary morphology/configuration - ANS annular, arciform, iris, linear, polymorphous,
punctuate, serpiginous, nummular/discoid, umbilicate, filiform, or verruciform
Lesion secondary morphology - ANS shape, size, arrangement, and distribution (asymmetric,
confluent. diffuse, discrete, generalized, grouped, localized.
satellite, symmetric, or zosteriform)
Infectious lesions - ANS acne, cellulitis, impetigo, German measles
(rubella), herpes simplex (cold sores), measles (rubeola),
pityriasis rosea, roseola, warts, candida, tinea corporis, and
tinea versicolour
Partial thickness wounds - ANS involve the epidermis and possibly the dermis
Full thickness wounds - ANS involve the dermis and subcutaneous tissue
The Braden Scale - ANS rates patients from 1 to 4 in each of six
, subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction
- A score from 14-18 on the Braden scale indicates a high risk of pressure ulcer development
The Norton Scale - ANS 1989). The Norton
scale rates patients from 1 to 4 in each of five subscales: physical
condition, mental condition, activity, mobility, and incontinence.
- A score <14 on the Norton scale indicates high risk of pressure ulcer development
Stages of pressure ulcers - ANS deep tissue, Stage I, Stage II, stage III, Stage IV, or
unstageable
- Stages I and II are partial thickness into the dermis
- Stages III and IV are full thickness
Wound drainage classifiction - ANS - serous (clear)
sanguineous (bloody)
- serosanguineous (mixed)
- fibrinous (sticky yellow)
- purulent (pus)
Non-pressure ulcers - ANS - neuropathic, venous (vascular), and arterial (vascular)
Burn classifications - ANS - based on depth of tissue destruction and percentage of total body
surface area (TBSA) affected
Burn levels - ANS Superficial burns:
- involve the epidermal layers
Superficial dermal burns:
- involve the epidermiss and all of the dermis
Total thickness burns:
- involve all layers of the skin and may extend into the supportive fascia below
Wallace rule of nines - ANS used to estimate percentage of TBSA burned in adults
The Lund and Browder burn estimation chart - ANS This chart and method for assigning
percentage of burns are commonly used in paediatric populations
Clubbing - ANS of the nails indicates chronic hypoxia
- identified when the angle of the nail to the finger is more than 160 degrees
Nail Inspection - ANS - Inspect each fingernail and toenail. Assess for colour,
thickness, and consistency
- Nails are smooth, translucent,
and consistent in colour and thickness. Longitudinal ridging
Sunblock - ANS deflect Uv rays from absorption
Sunscreens - ANS absorb harmful UV rays
general skin assessment - ANS includes color, texture, moisture, turgor, and temperature
Primary lesions - ANS lesions arising from previously normal skin including maculae, papules,
nodules, tumours, polyps, wheals, vesicles, cysts, pustules and abscesses
Secondary lesions - ANS results following primary skin lesions (scar tissue, crusts from dried
burns, etc.)
Vitiligo - ANS loss of pigment in areas of the skin
Unexpected color changes in skin - ANS flushing, erythema (redness), cyanosis (bluish
discolouration), pallor (paleness), rubor (dependant redness), brawny (dark leathery
appearance) and jaundice (yellow discolouration of skin and sclera)
uremic frost - ANS a whitish coating caused by urea and nitrogen skin excretion in the presence
of severe and prolonged kidney failure
Common benign lesions - ANS freckles, birthmarks, skin tags, moles, cherry angiomas
Lesion primary morphology/configuration - ANS annular, arciform, iris, linear, polymorphous,
punctuate, serpiginous, nummular/discoid, umbilicate, filiform, or verruciform
Lesion secondary morphology - ANS shape, size, arrangement, and distribution (asymmetric,
confluent. diffuse, discrete, generalized, grouped, localized.
satellite, symmetric, or zosteriform)
Infectious lesions - ANS acne, cellulitis, impetigo, German measles
(rubella), herpes simplex (cold sores), measles (rubeola),
pityriasis rosea, roseola, warts, candida, tinea corporis, and
tinea versicolour
Partial thickness wounds - ANS involve the epidermis and possibly the dermis
Full thickness wounds - ANS involve the dermis and subcutaneous tissue
The Braden Scale - ANS rates patients from 1 to 4 in each of six
, subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction
- A score from 14-18 on the Braden scale indicates a high risk of pressure ulcer development
The Norton Scale - ANS 1989). The Norton
scale rates patients from 1 to 4 in each of five subscales: physical
condition, mental condition, activity, mobility, and incontinence.
- A score <14 on the Norton scale indicates high risk of pressure ulcer development
Stages of pressure ulcers - ANS deep tissue, Stage I, Stage II, stage III, Stage IV, or
unstageable
- Stages I and II are partial thickness into the dermis
- Stages III and IV are full thickness
Wound drainage classifiction - ANS - serous (clear)
sanguineous (bloody)
- serosanguineous (mixed)
- fibrinous (sticky yellow)
- purulent (pus)
Non-pressure ulcers - ANS - neuropathic, venous (vascular), and arterial (vascular)
Burn classifications - ANS - based on depth of tissue destruction and percentage of total body
surface area (TBSA) affected
Burn levels - ANS Superficial burns:
- involve the epidermal layers
Superficial dermal burns:
- involve the epidermiss and all of the dermis
Total thickness burns:
- involve all layers of the skin and may extend into the supportive fascia below
Wallace rule of nines - ANS used to estimate percentage of TBSA burned in adults
The Lund and Browder burn estimation chart - ANS This chart and method for assigning
percentage of burns are commonly used in paediatric populations
Clubbing - ANS of the nails indicates chronic hypoxia
- identified when the angle of the nail to the finger is more than 160 degrees
Nail Inspection - ANS - Inspect each fingernail and toenail. Assess for colour,
thickness, and consistency
- Nails are smooth, translucent,
and consistent in colour and thickness. Longitudinal ridging
