Definitions
Assessment Pearls
Colors of the Rainbow
Hey, can you look at this?!
Name that lesion
100
Xerosis
What is dryness of skin and/or mucosal membrane?
100
Name what is being assessed.
What is skin turgor?
100
This skin coloration is caused by increased bilirubin in the blood.
What is jaundice?
100
A client goes to the clinic complaining of low energy and poor concentration. Upon assessment you see the following picture. How would you document this?
What is pallor?
100
What is ecchymoses?
200
Pruritus
What is itchy and dry skin?
200
Name an example of hypopigmentation patch.
What is vitiligo?
200
This coloration is caused by anemia, shock, or fear.
What is pallor?
200
Client is complaining of RUQ pain. You assess the client and notice their skin color is abnormal. How would you assess this?
What is jaundice?
200
What is a stage 3 pressure injury?
300
Seborrhea
What is oily skin or hair?
300
State what this means: ABCDE and what we are assessing for.
What is assessing for skin cancer: asymmetry, boarder, color, diameter, and evolution?
300
This coloration is caused by sunburns, burns, anger, or rosacea.
What is erythema?
300
A client is seen in the clinic, and upon assessment, you notice their hands appear just as seen in the following picture. How would you document the color?
What is cyanosis?
300
Coolness in only one foot or leg, pallor, elevational pallor, and dependent rubor; diminished pulses; systolic bruits; signs of malnutrition (thin, shiny skin; thick-ridged nails; atrophy of muscles); distal gangrene. Ulcers occur at toes, metatarsal heads, heels, and lateral ankle and are characterized by pale ischemic base, poor granulation, well-defined edges, and no bleeding; they look dry and punched out; may have eschar, indicating necrosis. Arterial ulcers are more common in those with smoking, diabetes, hyperlipidemia, and hypertension
What is an arterial ulcer?
400
senile purpura
What is vascularity of the skin diminishes while the vascular fragility increases; a minor trauma may produce dark red discolored areas?
400
State expected findings in the aging adults.
What is loss of melanocytes causing white or grey hair, loss of subcutaneous fat, loss of collagen and elasticity?
400
This coloration is caused by hypoxia.
What is cyanosis?
400
A client with low platelets is being admitted to your unit. Upon a head-to-toe skin assessment, you notice this on their back and chest. How would you document this?
What is purpura?
400
State the difference between CVI and VTE.
VTE:
S:Sudden onset of intense, sharp, deep muscle pain.
O:Increased warmth; swelling (to compare swelling, observe usual shoe size as in above photo); redness; dependent cyanosis is mild or may be absent; tender to palpation
CVI:
S:Aching, heaviness in calf, easy fatigability, restless legs, burning, throbbing, cramping. Localized itching, tingling, burning, or pain in these veins.21
O:Dilated, tortuous veins. New varicosities sit on surface of muscle or bone; older ones are deep and feel spongy. May see generalized leg swelling.
500
Vitiligo
What is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, and body folds and around orifices?
500
Describe the difference between hirsutism and alopecia.
What is hirsutism is male-pattered baldness or facial hair growth (shaggy or excessive hair), and alopecia is the loss of hair?
500
This coloration is caused by a loss of pigmentation.
What is hypopigmentation?
500
A client with heart failure is being seen for a follow-up visit. You assess their extremities and note edema in bilateral lower extremities. How would you document their edema?
What is a +2?
500
Your uncle hears you are in nursing school and decides to ask you health questions. He pulls up his pant leg and say, "Would you mind taking a look at this?" He says he has aching pain in calf that is worse at end of day. The pain gets worse with prolonged standing or sitting but lessens with leg elevation. He also notes there is itching. State what you believe your uncle is experiencing.
What is a chronic venous insufficiency?