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adeq./alter tissue
Clinical signs of adequate and altered tissue perfusion
| Question | Answer |
|---|---|
| Assessment Criterion: skin color Normal findings: | Pink |
| Assessment Criterion: skin Temp. Normal findings: | skin not excessively warm or cold |
| Assessment Criterion: Edema Normal findings: | absent |
| Assessment Criterion: skin texture Normal findings: | skin resilient, moist |
| Assessment Criterion: Arterial adequacy test Normal findings: | original color returns in 10 sec; veins in feet or hands fill in about 15 sec |
| Assessment Criterion: Capillary refill test Normal findings: | Immediate return of color w/in 2 sec |
| Assessment Criterion: peripheral pulse Normal findings: | easily palpable |
| Assessment Criterion: skin color abnormal findings | cyanotic pallor that increases with limb elevation, dusky red color with limb lowered, Browm pigmentatin around ankles |
| Assessment Criterion: skin color abnormalities caused by possible health problems | Cyanotic = venous insufficiency |
| Assessment Criterion: skin color abnormalities caused by possible health problems | Pallor that increased w/limb elevation = Arterial insufficiency |
| Assessment Criterion: skin color abnormalities caused by possible health problems | Dusky red color when limb lowered = Arterial insufficiency |
| Assessment Criterion: skin color abnormalities caused by possible health problems | Brown pigmentatin around ankles = Arterial insufficiency,chronic venous insufficiency |
| Assessment Criterion: skin Temp. of abnormal findings | skin cool |
| Assessment Criterion: skin Temp. abnormalities caused by possible health problems | skin cool = Arterial insufficiency |
| Assessment Criterion: Edema abnormal findings | marked edema; mild or absent |
| Assessment Criterion: edema abnormalities caused by possible health problems | Marked Edema = venous insufficiency Mild or absent =Arterial insufficiency |
| Assessment Criterion: skin texture abnormal findings | Skin thin and shiny or thick, waxy, shiny,and fragile, with reduced hair and ulceration |
| Assessment Criterion: skin texture abnormalities caused by possible health problems | Skin thin and shiny or thick, waxy, shiny,and fragile, with reduced hair and ulceration= Arterial or venous insufficiency |
| Assessment Criterion: Aterial adequacy test abnormal findings | delayed color return or mottled apperance; delayed venous filling; marked redness of arms or legs |
| Assessment Criterion: Aterial adequacy test abnormalities caused by possible health | delayed color return or mottled apperance; delayed venous filling; marked redness of arms or legs = Arterial insufficiency |
| Assessment Criterion: capillary refill test abnormal findings | Delayed return of color |
| Assessment Criterion: capillary refill test abnormalities caused by possible health | Delayed return of color = Arterial insufficiency |
| Assessment Criterion: peripheral pulse abnormal findings | no pulse, decreased or absent pulse |
| Assessment Criterion: peripheral pulse abnormalities caused by possible health | no pulse, decreased or absent pulse =Arterial insufficiency |
Created by:
ectolle
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