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Week 2 LAB

Terms in this set (50)

NonBlanchable Erythema
area of redness that persists (does not blanch/become pale) when pressure is applied to the area
Stage I Pressure Ulcer
not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.
Stage II Pressure Ulcer
the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
Stage III Pressure Ulcer
the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
Stage IV Pressure Ulcer
the pressure sore is very deep, reaching into muscle and bone (or cartilage) and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.
serum-filled
serosanguineous-filled blister
serum-filled
serum/blood-filled
Slough
Necrotic tissue
Eschar
Slough piece of tissue
undermining
tunneling
No skin borders
Wound tunnels from site of injury
Subcutaneous fat / tissue
Fatty layer under skin
osteomyelitis
osteitis
Bone infection
Bone inflammation
sDTI
Suspected deep tissue injury - usually older, may appear as bruise over heel, appears purple/maroon, intact skin or blood blister / thin blister
Etiology
Cause of, Set of causes
MRD Pressure Ulcer
Medical Related Device - ulcer forms from sustained pressure of device, higher in critically ill & peds , skin edema can contribute
Mucosal Pressure Ulcers
Cannot be classified due to mucosal membrane (in mouth)
Tissue Ischemia
Restriction of blood supply to tissue
Inflammation Phase
Proliferation Phase
Angiogenesis
Granulation
Epithelialization
Wound contraction
Maturation Phase (also called Remodeling Phase)
Inflammation Phase
Proliferation Phase
Maturation Phase (also called Remodeling Phase)
Erythema
Skin Redness - capillary vasodilation
Cyanosis
Bluish-gray skin - decreased oxygenation
Jaundice
yellowish skin eyes, mucous membranes - liver/gallbladder
Pallor
Pale skin from inadequate circulation, anemia.
Mottling
Bluish marbling macular lesions - blocked circulation
Ecchymosis (D: Area, Size, Date, Time)
Purplish patch - bleeding into the skin/under the skin.
Petechiae (D: Area, Size, Date, Time)
Pinpoint red/reddish-purple hemorrhage spots under skin from capillaries that are broken and bleeding occurs.
Hematoma (D: Area, Size, Date, Time)
Blood collecting outside blood vessel and collecting in a space, tissue, or organ where blood does not belong.
Wound
Assess / Doc: size, depth, shape, location, any drainage and what it looks like, and odor.
Rash
Assess / Doc: type of rash, size, if any difference in color, dry, wet, itching, or painful.
Skin moisture / texture
Assess for excessive moisture or dryness, Diaphoresis-excessive, rough or dry areas
Skin turgor
Pinch top of hand, Refers to the elasticity of the skin
Provides information about hydration status
Tenting-poor turgor, sign of dehydration
Edema
Excessive amount of fluid in the tissues
Labeled as 1+, 2+, 3+, 4+.
Skin may look shiny
Eye Assessment
Assess drainage, discoloration. Pupils equal size, black.
Mydriasis-dilated
glaucoma or med
Miosis-constricted
drugs
PEARL
Pupils Equal Reactive to Light
PERRLA
Pupils Equal Round Reactive to Light and Accommodation.
Ophthalmoscope
The instrument used to assess the eye.
Red reflex - why is this important?
Ear Assessment
Assess shape, size, and presence of lesions or break in skin. Should be symmetric, good placement. Palpate for edema, pain, temp.
Otoscope
GROW UP (adult) to see tympanic membrane.
GROW DOWN (3-)
Normal canal is smooth and pink in color. The tympanic membrane is intact and a dull gray without redness or discharge.
Pulse Assessment
Regular / Irregular rhythm?
Are they equal bilaterally?
Capillary Refill - Normal is 3 seconds or less
3+ Bounding
2+ Normal quality, not weak or bounding
1+ Diminished, thready, weak
0 Absent, unable to palpate (call code)
Abdominal Assessment
RUQ - Duodenum, gall bladder, liver, Rt. Kidney, colon, head of pancreas.
LUQ - Stomach, spleen, Lt. Kidney, flexure of colon, body of pancreas.
RLQ - Cecum, appendix, Rt. Ovary, Rt. ureter
LLQ - Sigmoid colon, Lt. ovary, Lt. ureter
Midline from umbilicus - Bladder and uterus
Inspect - symmetry, peristalsis, pulsation, masses.
Auscultate - ea quadrant, 1 min if no sounds
Increase - GI Upset, Diarrhea,
Decrease - Surgery, Obstruction
Bruit-swish - alt bld flow - aneurysm, stenosis
Percuss - Dr will perform
Palpate - ea quadrant, soft non-tender,
Abnormal - pain, spasm, distention, see face
Rebound Tenderness
tenderness occurs upon release of pressure on abdomen peritonitis, appendicitis
Lung Assessment
N: 12-20bpm, reg irreg, depth (shallow, deep, norm), symetry fall, A/P diameter 1:2, skin color & fingernail shape, trachea location, mental status
Crepitus
Crackling skin due to air in subcutaneous tissue (rice krispies).
Fingernail Clubbing
Poor oxygen
Chest Excursion
Feeling for chest expansion
Tactile Fremitus
Palpate for vibrations when pt. says "99", ^ fluid in lungs, decreased / absent fremitus decreased air movement, tissue consolidation
Crackles (rales)
Result from air movement through fluid-filled alveoli.
Discrete, non-continuous, usually heard on inspiration.
Fine-like rolling hair between fingers near ear.
Medium, coarse, or bubbling.
Wheezes
Result from air movement through narrowed or obstructed passage.
Inspiratory, expiratory or both
Change with coughing
Low pitched and coarse or high pitched and musical
Pleural Friction Rubs
Result from inflammation of visceral and parietal pleura as they rub during respiration.
Resembles sand paper sound
Tends to be heard in anterior-lateral chest.
Pulse Oximetry (SaO2)
% Hemoglobin molecules carrying oxygen. N: 92-100%
Below 85% oxygenation is inadequate.
Inaccurate: Movement, acrylic nails, nail polish, cold extremities
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