NUR 216 Exam 2 Study Guide UPDATED ACTUAL Questions
and CORRECT Answers
Assessment techniques for integumentary inspection and palpation
Inspection and palpation in skin color: expected findings -general pigmentation even and consistent
-appropriate for each ethnicity: whitish pink for light or dark brown with yellow or
olive tones
-increased pigmentation if exposed to sun
-hyperpigmentation: birthmarks, sun damage, freckles, tan lines.
-HyPOpigmentation: scars, stretch marks, vitiligo.
Inspection and palpation in skin color: unexpected pallor
findings erythema
cyanosis
juandice
pallor loss of color
black skin tones are gray especially in mucous membranes.
Brown skin tones a change to yellow-brown.
pale skin tones a loss of redness undertones
best places to see are: conjunctivae, lips, buccal, and mucosa
Causes: Anemia, shock, lack of blood flow
Erythema redness
hard to see on darker clients.
face, skin and pressure sore areas.
palpate skin for warmth and inflamed areas hard or tenderness
causes: inflammation/infection, vasodilation(dilation of blood vessels, increases
BP)
, Cyanosis light skin tones: bluish
palms and soles for darker skin tones.
brown skin tones change to a yellow.
black skin tones look grey.
best place to note in darker skin tones: mucous membranes and nail beds
Causes: hypoxia or impaired venous return
Juandice yellowing of the skin
skin, sclera, mucosa membranes
causes: liver dysfunction/disease, RBC destruction
temperature inspection for skin use dorsal of hand
expected findings:
-skin is warm
-temperature is equal bilaterally
moisture inspection for skin expected: dry
unexpected: diaphoretic (sweating heavily)
texture inspection for skin expected: smooth
expected variations: acne, wrinkles, scars
unexpected: velvety skin (thyroid disease) roughness, dryness (xerosis), flakiness
(indicates dehydration)
turgor inspection for skin dehydration or normal aging for a "tent"
clavicle location is ideal
edema in skin accumulation of fluid in the tissue
-skin i shiny and taut
-most common in legs
-assess over a bony area
-assess in all areas arms, legs and abdomen.
+1 is trace 2mm rapid return
+2 is mild 4mm 10-15 second return
+3 is moderate 6mm prolonged return
+4 is severe 8mm prolonged return
double amount for mm amount
vascular lesions results from blood leaking from blood vessels into the dermis
-Petechiae: infection or trauma.
-Ecchymosis: trauma (collection of blood in dermis >3 mm in diameter, can change
colors during healing (lead).
-purpura: infection or bleeding disorder
note the following for lesions color
height (above the skin)
shape
size (measured in cm)
-location and distribution on the body, if any exudate note the color and odor.
COCA (color, odor, consistency, amount)
and CORRECT Answers
Assessment techniques for integumentary inspection and palpation
Inspection and palpation in skin color: expected findings -general pigmentation even and consistent
-appropriate for each ethnicity: whitish pink for light or dark brown with yellow or
olive tones
-increased pigmentation if exposed to sun
-hyperpigmentation: birthmarks, sun damage, freckles, tan lines.
-HyPOpigmentation: scars, stretch marks, vitiligo.
Inspection and palpation in skin color: unexpected pallor
findings erythema
cyanosis
juandice
pallor loss of color
black skin tones are gray especially in mucous membranes.
Brown skin tones a change to yellow-brown.
pale skin tones a loss of redness undertones
best places to see are: conjunctivae, lips, buccal, and mucosa
Causes: Anemia, shock, lack of blood flow
Erythema redness
hard to see on darker clients.
face, skin and pressure sore areas.
palpate skin for warmth and inflamed areas hard or tenderness
causes: inflammation/infection, vasodilation(dilation of blood vessels, increases
BP)
, Cyanosis light skin tones: bluish
palms and soles for darker skin tones.
brown skin tones change to a yellow.
black skin tones look grey.
best place to note in darker skin tones: mucous membranes and nail beds
Causes: hypoxia or impaired venous return
Juandice yellowing of the skin
skin, sclera, mucosa membranes
causes: liver dysfunction/disease, RBC destruction
temperature inspection for skin use dorsal of hand
expected findings:
-skin is warm
-temperature is equal bilaterally
moisture inspection for skin expected: dry
unexpected: diaphoretic (sweating heavily)
texture inspection for skin expected: smooth
expected variations: acne, wrinkles, scars
unexpected: velvety skin (thyroid disease) roughness, dryness (xerosis), flakiness
(indicates dehydration)
turgor inspection for skin dehydration or normal aging for a "tent"
clavicle location is ideal
edema in skin accumulation of fluid in the tissue
-skin i shiny and taut
-most common in legs
-assess over a bony area
-assess in all areas arms, legs and abdomen.
+1 is trace 2mm rapid return
+2 is mild 4mm 10-15 second return
+3 is moderate 6mm prolonged return
+4 is severe 8mm prolonged return
double amount for mm amount
vascular lesions results from blood leaking from blood vessels into the dermis
-Petechiae: infection or trauma.
-Ecchymosis: trauma (collection of blood in dermis >3 mm in diameter, can change
colors during healing (lead).
-purpura: infection or bleeding disorder
note the following for lesions color
height (above the skin)
shape
size (measured in cm)
-location and distribution on the body, if any exudate note the color and odor.
COCA (color, odor, consistency, amount)
