NUR 216 Exam 2 – Questions With Appropriate Solutions
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Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
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Terms in this set (117)
Assessment techniques for integumentary inspection and palpation
Inspection and palpation in skin color: -general pigmentation even and consistent
expected findings -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: pallor
unexpected 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)
ABCDEs of melanoma A= asymmetry
B= border (irregular)
C= varies (brown, balck, tan)
D= diameter (usually >6mm)
E= evolving (looks different?)
flat lesions: macule freckles, mole, measles, scarlet fever
flat lesions: patch birthmark, vitiligo, hormonal changes
raised lesions: papule wart, elevated mole, skin tags
raised lesions: plaque psoriasis, eczema
raised solid lesions: tumor (neoplasm)
wheal (inspect bites, allergic reaction, hives
nodule(melanoma)
Save
Students also studied
Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
30 terms 24 terms 22 terms
jesssbee Preview kenanderson2017 Preview Brittany182
Terms in this set (117)
Assessment techniques for integumentary inspection and palpation
Inspection and palpation in skin color: -general pigmentation even and consistent
expected findings -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: pallor
unexpected 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)
ABCDEs of melanoma A= asymmetry
B= border (irregular)
C= varies (brown, balck, tan)
D= diameter (usually >6mm)
E= evolving (looks different?)
flat lesions: macule freckles, mole, measles, scarlet fever
flat lesions: patch birthmark, vitiligo, hormonal changes
raised lesions: papule wart, elevated mole, skin tags
raised lesions: plaque psoriasis, eczema
raised solid lesions: tumor (neoplasm)
wheal (inspect bites, allergic reaction, hives
nodule(melanoma)
