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Terms in this set (69)
What is a comprehensive patient A global assessment that provides insight on the
assessment? patient's medical status and factors that could impair
wound, ostomy, or continence progress. This helps
determine the etiology of the WOC issue..
What is a risk assessment? An assessment that assists in determining the
patient's level of risk in developing complications or
skin injury and development of a plan of care to
provide prevention/protection for the skin.
What 4 factors are included in the history, focused physical exam, identify barriers, and
comprehensive patient assessment? setting goals
What does OLDCART stand for? Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment
What are objective findings in a What you SEE, HEAR, SMELL, FEEL, and MEASURE.
focused physical exam?
VS, age, gender, appearance, cognitive function,
characteristics of WOC area, diagnostic assessments
(braden, fall, morse...), lab results
, What 4 factors need to be included in - patient centered
goal setting? - realistic and evidence-based
- short term
- long term
What is subjective data in a physical history of present problem, past medical history,
assessment? review of systems, medication review
Skin inspection vs assessment skin inspection is a visual observation from head to
toe
skin assessment is inspection plus palpation
What is a flat, circumscribed skin Macule
discoloration <0.5 cm. Ex) Freckle, flat
mole, petechia
What is a flat, nonpalpable, irregular- Patch
shaped macule >0.5 cm ex) Vitiligo,
port-wine stain
What is an elevated, firm, Papule
circumscribed palpable area of skin
<0.5 cm ex) Wart, elevated mole
What is an elevated, firm Nodule
circumscribed, palpable area deeper
in dermis than a papule >0.5 cm; tumor
if >2cm
What is an elevated, firm, rough lesion Plaque
with flat top surface >0.5 cm ex)
Psoriasis, seborrheic keratosis
What is an elevated, circumscribed, Vesicle
serous fluid beneath the epidermis
<0.5 cm ex) chicken pox, herpes
zoster