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Lewis Cp 24 Terms 3 of 3

Terms in this set (89)

Skin (structure and function)
Largest Organ
Primary role is protection
Other functions:
-regulate temperature
-sensory
-helps with synthesis of vit D
-structure and shape
-excretion
-identification
-reflects emotions
-diagnostic organ
Assessment: History and Physical
-Environmental Exposure: social (tanning, drug injections), occupational (lifeguard, chemical exposure, cooks-burns), cultural
-Complaint and symptoms
-PMH (past medical history..rashes, skin cancer)
-Medications (some make you more sensitive to sunlight)
Skin Inspection Elements
-color (and mucous membrane color)
-temperature
-moisture
-texture
-turgor
-edema
-lesions
-atraumatic
Turgor
pinch the hand and see if it recoils
-determines hydration
for a newborn, look at the fontanelles...bulging or sinking in
Lips Inspection Elements
-smooth
-pink
-moist
-atraumatic
Hair Inspection Elements
-texture
-color
Nails Inspection Elements
-slight curve
-smooth
Skin Palpation helps the nurse to assess...
-temp
-texture
-thickness
-moisture
-turgor
-edema
-lesions
-assessment of pulses
Objective Assessment vs. Subjective Assessment
Objective=measurable
Subjective=patient has to tell you
Edema Assessment
-push in with thumb (good place is ankles) and let go; see where it is, how far up it spreads, and how severe
-objective data with a degree of subjectivity
1+ mild pitting: no obvious swelling, slight indentation
2+ moderate pitting: indentation, but resolves rapidly
3+ deep pitting: indentation lasts a short time
4+ very deep pitting: indentation lasts a long time
Indentation lasts 15-30 seconds =
+3 to +4 Deep pitting to very deep pitting
Describing Skin Lesions (5)
1. Distribution
2. Location
3. Pattern
4. Exudate (what kind...color, smell, blood?)
5. Appearance (color, size, shape, texture, firmness)
Symptoms of skin disorders (4)
-itch
-drainage
-color change
-mole change
Normal Nail Appearance (3 ponits)
-160 degree angle between nail and finger skin
-smooth
-slight curve
Abnormal Nails (3 things and what to do)
1. Brittle, spilt, peel
-determine cause
-treated with lubricants (Biotin)
2. Nail infection (tinea unguium)
-culture
-treat with systemic antifungal
3. Paronychia
-topical antibiotics
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