What are basic critical thinking skills needed to identify and report deviations
from normal skin integrity?
Best time for skin assessment is during a bath; is the skin a consistent color
(other than tan lines); does the pt have frequent sun exposure; is anything
evolving/changing; present or past skin tenderness, describe raised areas /
discolorations (do not chart that it is a cyst, vitiligo, etc)
What are examples of ingeumentary assessments?
Skin color variations; freckles, moles, alopecia, hair color and quality,
presence of lesions, nails
Hair and scalp assessment includes
hair texture, color, scalp should move
What is the purpose of skin palpation?
Turgor check, texture, tenderness, blanchable erythema, presence of edema
What are the stages of edema?
Stage 1-4: Stage 1 = 2mm, Stage 2 = 4 mm, etc.
What type of edema is assessed when no interstitial fluid can be displaced?
Brawny Edema
What is the nurse assessing for when inspecting the nails?
nutrition (sp. protein intake); hygiene; body piercing; dehydration; nerve
damage; diabetes; bed rest; medications; radiation therapy
What labs are checked for protein levels?
Pre-albumin: short term
Albumin: long term (level over previous month)
What are the phases of wound healing
1. Hemostasis
2. Inflammatory
3. Proliferation
4. Maturation
What is involved in the hemostasis phase in wound healing?
Immediate Response
Constriction/Clotting
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