In which sequential order would the nurse perform the assessment of a lesion?

Q: Which assessment should the nurse complete first?

Inspection is a critical observation that should always occur first during an assessment (Jarvis, 2012). The correct answer is: B. Inspection. AUSCULTATION is usually performed following inspection, especially with abdominal assessment.

Q: In which order would the nurse complete a comprehensive assessment quizlet?

The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.

An extensive language has been developed to standardize the description of skin lesions, including

Inhaltsverzeichnis Show

Cross-section of the skin and skin structures
Which assessment should the nurse complete first?
In which order would the nurse complete a comprehensive assessment quizlet?
In which order would the nurse perform an assessment of the integumentary system?
In which order should the nurse perform an abdominal assessment for a client with a suspected bowel obstruction?

Rash is a general term for a temporary skin eruption.

Cross-section of the skin and skin structures

Macules are flat, nonpalpable lesions usually < 10 mm in diameter. Macules represent a change in color and are not raised or depressed compared to the skin surface. A patch is a large macule. Examples include freckles, flat moles, tattoos, and port-wine stains Capillary Malformations Capillary malformations are present at birth and appear as flat, pink, red, or purplish lesions. Port-wine stains are capillary vascular malformations that are present at birth and that manifest... read more

, and the rashes of rickettsial infections Overview of Rickettsial and Related Infections Rickettsial diseases (rickettsioses) and related diseases (anaplasmosis, ehrlichiosis, Q fever, scrub typhus) are caused by a group of gram-negative, obligately intracellular coccobacilli. All... read more

, rubella Rubella ( See also Congenital Rubella.) Rubella is a contagious viral infection that may cause adenopathy, rash, and sometimes constitutional symptoms, which are usually mild and brief. Infection during... read more

, measles Measles Measles is a highly contagious viral infection that is most common among children. It is characterized by fever, cough, coryza, conjunctivitis, an enanthem (Koplik spots) on the oral mucosa... read more

(can also have papules and plaques), and some allergic drug eruptions Drug Eruptions and Reactions Drugs can cause multiple skin eruptions and reactions. The most serious of these are discussed elsewhere in THE MANUAL and include Stevens-Johnson syndrome and toxic epidermal necrolysis, hypersensitivity... read more

Papules are elevated lesions usually < 10 mm in diameter that can be felt or palpated. Examples include nevi, warts, lichen planus Lichen Planus Lichen planus is a recurrent, pruritic, inflammatory eruption characterized by small, discrete, polygonal, flat-topped, violaceous papules that may coalesce into rough scaly plaques, often accompanied... read more

, insect bites, seborrheic keratoses Seborrheic Keratoses Seborrheic keratoses are superficial, often pigmented, epithelial lesions that are usually warty but may occur as smooth papules. The cause of seborrheic keratosis is unknown, but genetic mutations... read more

, actinic keratoses Actinic keratoses Chronic affects of sunlight include photoaging, actinic keratoses, and skin cancer. (See also Overview of Effects of Sunlight.) Chronic exposure to sunlight ages the skin (photoaging, dermatoheliosis... read more

, some lesions of acne Acne Vulgaris Acne vulgaris is the formation of comedones, papules, pustules, nodules, and/or cysts as a result of obstruction and inflammation of pilosebaceous units (hair follicles and their accompanying... read more

, and skin cancers Overview of Skin Cancer Skin cancer is the most common type of cancer and commonly develops in sun-exposed areas of skin. The incidence is highest among outdoor workers, sportsmen, and sunbathers and is inversely related... read more . The term maculopapular is often loosely and improperly used to describe many red rashes; because this term is nonspecific and easily misused, it should be avoided.

Pustules are vesicles that contain pus. Pustules are common in bacterial infections and folliculitis and may arise in some inflammatory disorders including pustular psoriasis Subtypes of Psoriasis

Urticaria Urticaria Urticaria consists of migratory, well-circumscribed, erythematous, pruritic plaques on the skin. Urticaria also may be accompanied by angioedema, which results from mast cell and basophil activation... read more

(wheals or hives) is characterized by elevated lesions caused by localized edema. Wheals are pruritic and red. Wheals are a common manifestation of hypersensitivity to drugs, stings or bites, autoimmunity, and, less commonly, physical stimuli including temperature, pressure, and sunlight. The typical wheal lasts < 24 hours.

Scale is heaped-up accumulations of horny epithelium that occur in disorders such as psoriasis Psoriasis Psoriasis is an inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with silvery scales. Multiple factors contribute, including... read more

, seborrheic dermatitis Seborrheic Dermatitis Seborrheic dermatitis is a common inflammatory condition of skin regions with a high density of sebaceous glands (eg, face, scalp, sternum). The cause is unknown, but species of Malassezia... read more

, and fungal infections. Pityriasis rosea Pityriasis Rosea Pityriasis rosea is a self-limited, inflammatory disease characterized by diffuse, scaling papules or plaques. Treatment is usually unnecessary. Pityriasis rosea most commonly occurs between... read more

and chronic dermatitis of any type may be scaly.

Erosions are open areas of skin that result from loss of part or all of the epidermis. Erosions can be traumatic or can occur with various inflammatory or infectious skin diseases. An excoriation is a linear erosion caused by scratching, rubbing, or picking.

Petechiae are nonblanchable punctate foci of hemorrhage. Causes include platelet abnormalities (eg, thrombocytopenia, platelet dysfunction Overview of Platelet Disorders Platelets are circulating cell fragments that function in the clotting system. Thrombopoietin helps control the number of circulating platelets by stimulating the bone marrow to produce megakaryocytes... read more

), vasculitis Overview of Vasculitis Vasculitis is inflammation of blood vessels, often with ischemia, necrosis, and organ inflammation. Vasculitis can affect any blood vessel—arteries, arterioles, veins, venules, or capillaries... read more

, and infections (eg, meningococcemia, Rocky Mountain spotted fever Rocky Mountain Spotted Fever (RMSF) Rocky Mountain spotted fever (RMSF) is caused by Rickettsia rickettsii and transmitted by ixodid ticks. Symptoms are high fever, severe headache, and rash. (See also Overview of Rickettsial... read more

, other rickettsioses).

Purpura is a larger area of hemorrhage that may be palpable. Palpable purpura is considered the hallmark of leukocytoclastic vasculitis. Purpura may indicate a coagulopathy. Large areas of purpura may be called ecchymoses or, colloquially, bruises.

Telangiectases are foci of small, permanently dilated blood vessels that may occur in areas of sun damage, rosacea Rosacea Rosacea is a chronic inflammatory disorder characterized by facial flushing, telangiectasias, erythema, papules, pustules, and, in severe cases, rhinophyma. Diagnosis is based on the characteristic... read more

, systemic diseases (especially systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare chronic disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs (especially the esophagus... read more

), or inherited diseases (eg, ataxia-telangiectasia Ataxia-Telangiectasia Ataxia-telangiectasia results from a DNA repair defect that frequently results in humoral and cellular deficiency; it causes progressive cerebellar ataxia, oculocutaneous telangiectasias, and... read more , hereditary hemorrhagic telangiectasia Hereditary Hemorrhagic Telangiectasia Hereditary hemorrhagic telangiectasia is a hereditary disorder of vascular malformation transmitted as an autosomal dominant trait affecting men and women. (See also Overview of Vascular Bleeding... read more

) or after long-term therapy with topical fluorinated corticosteroids.

Configuration is the shape of single lesions and the arrangement of clusters of lesions.

Reticulated lesions have a lacy or networked pattern. Examples include cutis marmorata and livedo reticularis.

Some skin lesions have visible or palpable texture that suggests a diagnosis.

Lichenification is thickening of the skin with accentuation of normal skin markings; it results from repeated scratching or rubbing.

Xanthomas, which are yellowish, waxy lesions, may be idiopathic or may occur in patients who have lipid disorders.

It is important to note whether

Lesions are single or multiple.
Particular body parts are affected (eg, palms or soles, scalp, mucosal membranes).
Distribution is random or patterned, symmetric or asymmetric.
Lesions are on sun-exposed or protected skin.

Although few patterns are pathognomonic, some are consistent with certain diseases.

Lichen planus Lichen Planus Lichen planus is a recurrent, pruritic, inflammatory eruption characterized by small, discrete, polygonal, flat-topped, violaceous papules that may coalesce into rough scaly plaques, often accompanied... read more

frequently arises on the wrists, forearms, genitals, and lower legs.

When examining the color of skin, health care practitioners should note that the natural color of a patient's skin can change the appearance of colors.

Red skin (erythema) can result from many different inflammatory or infectious diseases. Cutaneous tumors are often pink or red. Superficial vascular lesions such as port-wine stains may appear red.

Orange skin is most often seen in hypercarotenemia, a usually benign condition of carotene deposition after excess dietary ingestion of beta-carotene.

Violet skin may result from cutaneous hemorrhage or vasculitis Overview of Vasculitis Vasculitis is inflammation of blood vessels, often with ischemia, necrosis, and organ inflammation. Vasculitis can affect any blood vessel—arteries, arterioles, veins, venules, or capillaries... read more

. Vascular lesions or tumors, such as Kaposi sarcoma Kaposi Sarcoma Kaposi sarcoma is a multicentric vascular tumor caused by herpesvirus type 8. It can occur in classic, AIDS-associated, endemic (in Africa), and iatrogenic (eg, after organ transplantation)... read more

and hemangiomas, can appear purple. A lilac color of the eyelids or heliotrope eruption is characteristic of dermatomyositis Autoimmune Myositis Autoimmune myositis is characterized by inflammatory and degenerative changes in the muscles (polymyositis, necrotizing immune-mediated myopathy) or in the skin and muscles (dermatomyositis)... read more

Shades of blue, silver, and gray can result from deposition of drugs or metals in the skin, including minocycline, amiodarone, and silver (argyria). Ischemic skin appears purple to gray in color. Deep dermal nevi appear blue.

Black skin lesions may be melanocytic, including nevi and melanoma Melanoma Malignant melanoma arises from melanocytes in a pigmented area (eg, skin, mucous membranes, eyes, or central nervous system). Metastasis is correlated with depth of dermal invasion. With spread... read more

. Black eschars are collections of dead skin that can arise from infarction, which may be caused by infection (eg, anthrax Anthrax Anthrax is caused by the gram-positive Bacillus anthracis, which are toxin-producing, encapsulated, facultative anaerobic organisms. Anthrax, an often fatal disease of animals, is transmitted... read more

, angioinvasive fungi including Rhizopus, meningococcemia Meningococcal Diseases Meningococci (Neisseria meningitidis) are gram-negative diplococci that cause meningitis and meningococcemia. Symptoms, usually severe, include headache, nausea, vomiting, photophobia... read more

), calciphylaxis Calciphylaxis All patients undergoing long-term renal replacement therapy (RRT) develop accompanying metabolic and other disorders. These disorders require appropriate attention and adjunctive treatment.... read more

, arterial insufficiency, or vasculitis Cutaneous Vasculitis Cutaneous vasculitis refers to vasculitis affecting small- or medium-sized vessels in the skin and subcutaneous tissue but not the internal organs. Cutaneous vasculitis may be limited to the... read more

Dermatographism (dermographism) is the appearance of an urticarial wheal after focal pressure (eg, stroking or scratching the skin) in the distribution of the pressure. Up to 5% of normal patients may exhibit this sign, which is a form of physical urticaria.

Koebner phenomenon describes the development of lesions within areas of trauma (eg, caused by scratching, rubbing, or injury). Psoriasis frequently exhibits this phenomenon, as may lichen planus Lichen Planus Lichen planus is a recurrent, pruritic, inflammatory eruption characterized by small, discrete, polygonal, flat-topped, violaceous papules that may coalesce into rough scaly plaques, often accompanied... read more

, often resulting in linear lesions.

Which assessment should the nurse complete first?

Inspection is a critical observation that should always occur first during an assessment (Jarvis, 2012). The correct answer is: B. Inspection. AUSCULTATION is usually performed following inspection, especially with abdominal assessment.

In which order would the nurse complete a comprehensive assessment quizlet?

The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.

In which order would the nurse perform an assessment of the integumentary system?

Focused Assessments.

In which order should the nurse perform an abdominal assessment for a client with a suspected bowel obstruction?

In which order should the nurse perform an abdominal assessment for a client with a suspected bowel obstruction? The normal order of assessment would be inspection, palpation, percussion, and auscultation.