NUR 216 - Module 4 EXAM 2024/2025 WITH 100% VERIFIED SOLUTIONS HEALTH ASSESSMENT
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Course
NUR 216
Institution
NUR 216
NUR 216 - Module 4 EXAM 2024/2025
WITH 100% VERIFIED SOLUTIONS
HEALTH ASSESSMENT
NUR 216 - Module 4 EXAM 2024/2025
WITH 100% VERIFIED SOLUTIONS
HEALTH ASSESSMENT
Bulla - Elevated serous filled greater than 1cm. ex. blister
Capillary Refill - -Depress the nail edge to blanch a...
NUR 216 - Module 4 EXAM 2024/2025
WITH 100% VERIFIED SOLUTIONS
HEALTH ASSESSMENT
, NUR 216 - Module 4 EXAM 2024/2025
WITH 100% VERIFIED SOLUTIONS
HEALTH ASSESSMENT
Bulla - ✓✓Elevated serous filled greater than 1cm. ex. blister
Capillary Refill - ✓✓-Depress the nail edge to blanch and then release
-Should be less than two seconds
-Delayed cap refill could indicate cardiovascular or respiratory dysfunction
Deep Tissue Injury (DTI) - ✓✓Discoloration but skin intact, damage to underlying
tissue.
Dermis - ✓✓The middle layer is composed of connective tissue that is formed by a
dense combination of interconnecting collagen and elastic fibers. It contains blood
vessels, hair follicles, cutaneous nerve endings, sensory receptors, lymphatics, ans
sebaceous and sweat glands.
Ecchymosis - ✓✓Collection of blood in the dermis greater than 3mm in diameter.
Initially reddish-purple, but will change to blue or yellow during healing, caused by
trauma
Edema (accumulation of fluid in tissue) - ✓✓-Skin appears shinny and tight
-Assess in all areas (arms, legs, abdomen)
-Assess over a bony area (shin)
Edema Scale - ✓✓+1 = trace, 2mm, rapid return
+2 = mild, 4mm, 10-15 second return
+3 = moderate, 6mm, prolonged return, 30 seconds
+4 = severe, 8mm, prolonged return, greater than 30 seconds
Elasticity in the older adult. - ✓✓-Loses elasticity; skin folds and sags.
-Decreased skin turgor.
Epidermis - ✓✓The surface layer is a combination of dead cells on the outside and live
cells on the inside. It takes about a month for cells to move from the inner surface to the
outer surface. This is a way the skin constantly renews itself.
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