WHA Skin Assessment

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45 Terms

1
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cyanosis

light skin: bluish

dark skin: ashen gray

2
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pallor paleness

light skin: loss of rosy glow

dark skin: ashen gray, yellowish brown

3
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erythema redness

light skin: visible redness

dark skin: rely on palpation or warmth, edema

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petechiae small pinpoint

light skin: purplish pinpoints

dark skin: usually invisible, check oral mucosa, conjunctiva, eyelids

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malignant skin lesions

  • basal cell carcinoma

  • squamous cell carcinoma

  • malignant melanomas

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macules

solely a color change, flat & circumscribes, less than 1cm

<p>solely a color change, flat &amp; circumscribes, less than 1cm</p><p></p>
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patches

macules larger than 1cm

<p>macules larger than 1cm</p>
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papule

felt & caused by superficial thickening of the epidermis

<p>felt &amp; caused by superficial thickening of the epidermis</p>
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plaques

papules coalescing by superficial thickening of the epidermis

<p>papules coalescing by superficial thickening of the epidermis</p>
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wheal

superficial, raised, transient, and erythematous; irregular in shape due to edema

<p>superficial, raised, transient, and erythematous; irregular in shape due to edema</p>
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urticaria (hives)

wheals coalesce to form extensive pruritic reaction

<p>wheals coalesce to form extensive pruritic reaction</p>
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vesicles

elevated cavity containing fluid up to 1cm (blister)

<p>elevated cavity containing fluid up to 1cm (blister)</p>
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bulla

larger than 1cm, usually single chamber, superficial in dermis & ruptures easily

<p>larger than 1cm, usually single chamber, superficial in dermis &amp; ruptures easily</p>
14
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cysts

encapsulated fluid dilled cavity

<p>encapsulated fluid dilled cavity</p>
15
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pustules

pus in cavity that is circumscribed & elevated

<p>pus in cavity that is circumscribed &amp; elevated</p>
16
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nodule

solid elevated, hard or soft, greater than 1cm, may extend deeper into dermis than papule

<p>solid elevated, hard or soft, greater than 1cm, may extend deeper into dermis than papule</p>
17
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tumor

larger in diameter, firm or soft, deeper into dermis, benign or malignant

<p>larger in diameter, firm or soft, deeper into dermis, benign or malignant</p>
18
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telangiectases

spider star or spider angioma, rosacea

<p>spider star or spider angioma, rosacea</p>
19
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crust

thickened dried out exudate

<p>thickened dried out exudate</p>
20
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scale

compact flakes of desiccated skin from shedding dead excess keratin cells

<p>compact flakes of desiccated skin from shedding dead excess keratin cells</p>
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fissures

linear crack w/ abrupt edges extending into dermis

<p>linear crack w/ abrupt edges extending into dermis</p>
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erosions

scooped out but shallow depression

<p>scooped out but shallow depression</p>
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ulcers

deeper depression extending into dermis w/ irregular shape, may bleed, leaves scar

<p>deeper depression extending into dermis w/ irregular shape, may bleed, leaves scar</p>
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scar

permanent fibrotic change after healing

<p>permanent fibrotic change after healing</p>
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atrophic scares

resulting skin level is depressed w/ loss of tissue & thinning

<p>resulting skin level is depressed w/ loss of tissue &amp; thinning</p>
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lichenification

prolonged intense scratching leading to thickened skin producing tightly packed set of papules

<p>prolonged intense scratching leading to thickened skin producing tightly packed set of papules</p>
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keloids

benign excess of scar tissue beyond original injury

<p>benign excess of scar tissue beyond original injury</p>
28
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excoriations

self-inflicted abrasion that is superficial

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hemangiomas

  • port win stain (nevus flammeus)

  • strawberry mark (immature)

  • cavernous hemangioma (mature)

<ul><li><p>port win stain (nevus flammeus)</p></li><li><p>strawberry mark (immature)</p></li><li><p>cavernous hemangioma (mature)</p></li></ul><p></p>
30
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purpuric legions

petichae, ecchymosis, purpura

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annular or circular

begins in center & spreads to periphery

<p>begins in center &amp; spreads to periphery</p>
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confluent

lesions run together

<p>lesions run together</p>
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discrete

distinct & separate

<p>distinct &amp; separate</p>
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grouped

cluster of lesions

<p>cluster of lesions</p>
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gyrate

twisted, coiled, or snakelike

<p>twisted, coiled, or snakelike</p>
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target or iris

resembles iris of eyes, concentric rings

<p>resembles iris of eyes, concentric rings</p>
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linear

scratch, streak, line, or stripe

<p>scratch, streak, line, or stripe</p>
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polycyclic

annular lesions grow together

<p>annular lesions grow together</p>
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zosteriform

linear arrangement following a unilateral nerve route

<p>linear arrangement following a unilateral nerve route</p>
40
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stage 1 pressure ulcer

  • intact skin w/ localized are of non-blanchable erythema

<ul><li><p>intact skin w/ localized are of non-blanchable erythema</p></li></ul><p></p>
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stage 2 pressure ulcer

  • partial thickness loss of skin w/ exposed dermis

  • adipose not visible

<ul><li><p>partial thickness loss of skin w/ exposed dermis</p></li><li><p>adipose not visible</p></li></ul><p></p>
42
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stage 3 pressure ulcer

  • full thickness loss of skin

  • adipose is visible

  • granulation tissue and epibole (rolled wound edges) often present

<ul><li><p>full thickness loss of skin</p></li><li><p>adipose is visible</p></li><li><p>granulation tissue and epibole (rolled wound edges) often present</p></li></ul><p></p>
43
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stage 4 pressure ulcer

  • full thicken skin & tissue loss w/ exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

  • epibole, slough, and eschar often visible-

<ul><li><p>full thicken skin &amp; tissue loss w/ exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer</p></li><li><p>epibole, slough, and eschar often visible-</p></li></ul><p></p>
44
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unstageable pressure ulcer

  • full thickness skin & tissue loss to extent that damage cannot be confirmed due to slough or eschar obscuring it

<ul><li><p>full thickness skin &amp; tissue loss to extent that damage cannot be confirmed due to slough or eschar obscuring it</p></li></ul><p></p>
45
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Braden scale

predicts pressure sore risks from

  • sensory perception

  • moisture

  • activity

  • mobility

  • nutrition

  • friction & shear