What is a comprehensive patient assessment? - Answers A global assessment that provides insight on
the 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? - Answers 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 comprehensive patient assessment? - Answers history, focused
physical exam, identify barriers, and setting goals
What does OLDCART stand for? - Answers Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment
What are objective findings in a focused physical exam? - Answers What you SEE, HEAR, SMELL, FEEL,
and MEASURE.
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 goal setting? - Answers - patient centered
- realistic and evidence-based
- short term
- long term
What is subjective data in a physical assessment? - Answers history of present problem, past medical
history, review of systems, medication review
Skin inspection vs assessment - Answers skin inspection is a visual observation from head to toe
skin assessment is inspection plus palpation
What is a flat, circumscribed skin discoloration <0.5 cm. Ex) Freckle, flat mole, petechia - Answers
Macule
What is a flat, nonpalpable, irregular-shaped macule >0.5 cm ex) Vitiligo, port-wine stain - Answers
Patch
What is an elevated, firm, circumscribed palpable area of skin <0.5 cm ex) Wart, elevated mole -
Answers Papule
What is an elevated, firm circumscribed, palpable area deeper in dermis than a papule >0.5 cm; tumor
if >2cm - Answers Nodule
What is an elevated, firm, rough lesion with flat top surface >0.5 cm ex) Psoriasis, seborrheic keratosis
- Answers Plaque
What is an elevated, circumscribed, serous fluid beneath the epidermis <0.5 cm ex) chicken pox,
herpes zoster - Answers Vesicle
What is an elevated, superficial lesion like a vesicle but filled with purulent fluid? ex) acne, impetigo -
Answers Pustule
What is an elevated, circumscribed, encapsulated lesion in the dermis or subcutaneous layer; filled
with liquid or semisolid material? - Answers Cyst
What is a circumscribed, irregular-shaped, elevated area of cutaneous edema; solid, transient ex) bug
bite, allergic reaction, TB test - Answers Wheal
What is a vesicle >0.5 cm - Answers Bulla
What are the fine, irregular lines produced by capillaries? Ex) Rosacea around nose, spider veins -
Answers Telangiectasia
What are palpable and nonpalpable red or violaceous discoloration due to extravasation of blood in
the skin or vascular inflammation? - Answers Purpura
What is extravasation of blood into the skin or mucous membranes? Flat, color changes progress over
time. - Answers Bruise/ecchymosis
What are the time 1-2 mm, red macules that result from tiny hemorrhages? - Answers Petechiae