NU- 305 unit one general survey, skin

what is a general survey

study of the whole person, covering the general health state and any obvious physical characteristics

what is expected for facial

symmetry

what is unexpected for facial survey

expressionless, asymmetry, involuntary movement, swelling, lesions, excessive bleeding

What does the general survey include?

physical appearance, body structure, mobility, behavior

what is expected for emotional status

relaxed, smiling, responsive

what is unexpected for emotional status

restlessness, quiet, grimacing, squinting

what is confusion

loss of ability to think rapidly and clearly; impaired judgement and decision making

What is lethargy?

Limited spontaneous movement, sluggish speech, drowsy, falling asleep quickly

what is stupor

Partial or almost complete unconsciousness.

what is comatose

being unable to respond to stimuli

What is obtundation?

mild to moderate reduction in arousal (awakeness) with limited response to the environment - falls asleep unless stimulated verbally or tactilely

what is expected with skin

warm, intact, even tones

what is unexpected for skin

cool/hot, diaphoresis, clamminess, tone variation

what is expected for speech

pace, fluency, articulation

what is unexpected for speech

whispering, abnormal tone or pace

what is cushings

Hypersecretion of glucocorticoids from the adrenal cortex

what is compartment syndrome

Damage to nerves and vasculature of an extremity due to compression

what is a tremor

rhythmic, involuntary, purposeless contraction that produces a quivering or shaking movement

what is chronic pain

Pain continues for 6 months or longer

what is acute pain

sudden onset, usually subsides once treated

what is visceral pain

organ pain

What is somatic pain?

originating from muscle, bone, joints, tendons, or blood vessels

What is reffered pain?

pain felt in another part of the body then where it occurs

what is the epidermis

Outer layer of skin

what is the dermis

Support layer below the epidermis

What is the subcutaneous layer?

layer of connective tissue (adipose and LCT) that binds the skin to underlying structures.

what is keratin

tough fibrous protein

what is the nail bed

Portion of the living skin that supports the nail plate as it grows towards the free edge.

what is vitiligo

Lack of pigment, white patches.

what is chiloasma

melasma, dark symmetrical patches that appear on the face

who does chiloasma affect typically

pregnant women

what is cafe au laite

birth marks

what is solar lentigines

Acquired macules on sun exposed areas (liver spots)

what is hyperpigmentation

Over-production of Melanin pigment

what is jaundice

A yellowing of the skin and eyes

what is petechiae

Small dot like pinpoint hemorrhages on the skin.

what is ecchymosis

bruising of the skin

what is expected skin texture

smooth, uniformly dry

what is unexpected skin texture

velvety(thyroid disease), roughness

what is skin texture variation

acne, wrinkles, scars

what is purpura

collection of petechiae and ecchymosis covering an area

what is a macule

a flat lesion that differs in color from surrounding skin (

what is a patch

A small, circumscribed area differing in color from the surrounding surface (>1 cm in diameter)

what is a papule

small elevation of the skin that contains no fluid and may develop pus

what is a plaque

A build up of cholesterol along the walls of arteries (fatty material)

what is wheal

A raised, swollen, well-defined area on the skin

what is a nodule

A solid bump that is usually larger than one centimeter

what is a vesicle

A small, membrane bound compartment

what is a bulla

large blister containing watery fluid that is larger than a vesicle

what is a pustule

An infected papule with fluid inside.

what is a cyst

Deep infection caused by a deep massive invasion of white blood cells

what is lichenification

thickening of the epidermis

what is scale

excessive shedding of keratin cells from the epidermis

what is an ulceration

erosion and inflammation of an epithelial surface

What are the ABCDE's of skin cancer?

asymmetry, border, color, diameter, evolving

what is a pressure injury

Localized damage to the skin and underlying soft tissue usually over a bony prominence

what is a stage one pressure injury

redness of the skin, warmness

what is a stage 2 pressure injury

partial loss of dermis, shiny or dry ulcer with pink wound bed, may present as intact or ruptured blister

what is a stage 3 pressure ulcer

Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present

what is a stage 4 pressure ulcer

Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling

what is an unstageable ulcer

Full thickness tissue loss where the base of the ulcer is completely covered by slough (yellow, tan, gray, green, or brown) and/or eschar in the wound bed (must remove slough to expose base)

What helps wound healing?

proper care, good moisture, good nutrition

what prevents wound healing ?

smoking, letting it dry out, infection