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Types of assessment -ANSWER--comprehensive
-focused
-baseline
-functional
what are the 4 steps of health assessment? -ANSWER-1) health history
2) physical assessment
3) clinical reasoning
4) documentation/communication
medical diagnosis -ANSWER-focus is on the diagnosis of disease
nursing diagnosis -ANSWER-focus is on patient's actual/potential
response to health problems
primary lesions ________________________ -ANSWER-arise from
normal skin
,name the 3 types of vascular lesions -ANSWER--hemangiomas
-telangiectasias
-pupuric lesions
examples of hemangiomas -ANSWER--port wine stain
-strawberry hemangioma
-cavernous hemangioma
-cherry angioma
telangiectasias -ANSWER--telangiectasia
-spider angiomas
-venous lake
purpuric lesions -ANSWER--petechiae
-ecchymosis
-pupura
ABCDE of skin assessment -ANSWER-A: asymmetry
B: border
C: color
D: diameter
, E: evolution and elevation
Braden Scale -ANSWER-sensory perception, moisture, activity, mobility,
nutrition, friction and shear
Braden scale scoring -ANSWER-15-18 = at risk
13-14 = moderate risk
10-12 = high risk
9 or less = very high risk
if score is ≤ 18 add risk for skin breakdown to nursing care plan and
initiate interventions
_______% of ulcers occur in the pelvic area -ANSWER-62
Stages of pressure ulcers -ANSWER-Stage 1) non-blanchable erythema
Stage 2) partial thickness skin loss
Stage 3) full thickness skin loss, can see SC tissue
Stage 4) involves muscle, bone
deep tissue injury -ANSWER-deep bruise, feels squishy
basal cell carcinoma -ANSWER--most common
-pearly papule