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NUR 216 Exam 2 Study Guide Exam Questions and Answers
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NUR 216 Exam 2 Study Guide Exam Questions and Answers
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NUR 216 Exam 2 Study Guide ExamQuestions and 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 findings - -pallor
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)
-raised, fluid lesions (vesicles) - -pustule (acne, cold sore)
cyst: cystic acne, sebaceous cyst
bulla: blister, medication reaction
-secondary lesions - -revolve from primary lesions and with time the
characteristics change:
-crust, scaling, ulcers
-pressure injuries/ulcers risk factors - -risk factors:
-elderly: thinning skin and less SQ fat
-excessive moisture (urinary issues or fecal)
-shearing and friction
-immobility
-obesity
-poor nutrition and hydration
-vascular disease (lack of circulation)
-sensory deficits
-edema
-chronic disease(DM, liver failure
-pressure points for injuries - -Supine:
back of head
shoulder
elbow
butt
heel
Side laying (lateral):
ear
shoulder
elbow
hip
thigh
leg
heel
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