181 Unit 3

Question 1

Skin

Answer 1

The skin is the body first line of defense protecting the underlying structure from invasion by organism.The largest organ of the body and has multiple functions. Essential for maintaining life. I have three layers epidermis dermis and subcutaneous tissue. Functions of the skin protection temperature regulation Psychosocial sensation vitamin D production immunologic absorption and elimination.

Question 2

Protection

Answer 2

Act as a barrier to water,Micro organism and damaging ultraviolet rays of the sun protect against infection injury to underlying tissue and organs is decreased by intact skin prevent loss of moisture from the surface and underlining structure.

Question 3

Temperature regulation

Answer 3

The evaporation of perspiration draw heat from the skin. Blood vessel in the skin dilate to dissipate heat and cold condition blood vessel in the skin constrict to diminish heat loss. In cold condition contraction of polo motor Muscles cause the hair to stand on the ends forming a layer of air on the body for insulation.

Question 4

Psycho social

Answer 4

External appearance is a major contributor to self-esteem skin play an important role in identification and communication

Question 5

Sensation

Answer 5

Millions of nerve ending in the Skin provide a sense of touch pain pleasure in temperature.Sensory impulses from the skin allow the body to adjust to the environment in conjunction with the brain and spinal cord

Question 6

Vitamin D production

Answer 6

A precursor for vitamin D is present in the skin which in conjunction with ultraviolet rays from the sun produce vitamin D

Question 7

Immunologic

Answer 7

A breach in the surface of the skin trigger immunologic response in the skin

Question 8

Absorption

Answer 8

Substance such as medication can beAbsorbed through the skin

Question 9

Elimination

Answer 9

Water electrolytes and nitrogenous Waste are excreted in small amount in sweat

Question 10

Factors placing an individual at risk for skin alternations

Answer 10

Lifestyle variables age change in health state illness diagnostic measures therapeutic measures

Question 11

Lifestyle variables, Homosexuality,Occupation,Body piercing

Answer 11

These patients are at risk for infection with human immune deficiency virus(hiv) Can acquire immune deficiency syndrome(aids). Assessment need to include careful examination of the skin for purple blotch is that may be indicated of sarcoma. Assessment needs to include careful examination for a sore does not heal or a change in size or color of a wart or mole. Places person at high risk for developing skin cancer. Potential interference With airway management potential risk for bacterial and viral infection scarring nerve damage tissue trauma and deformity.Assess patient knowledge of symptoms of infection at the site and went to seek medical care.Process piercing site for redness swelling or discharge or excessive pain.

Question 12

Age related to skin alteration - subcutaneous and dermal tissue become thin

Answer 12

Skin or more easily injured.Skin has less capability to insulate. Wrinkles more easily.Sensation of pressure and pain is reduced. Nursing strategies -Do not apply tape to skin unless necessary,Check skin frequently to observe for any signs of a pressure ulcer, Pad bony prominence if necessary, Assess pressure tolerance by checking pressure points for redness after 30 minutes.

Question 13

Age related skin integrity - activity of the sebaceous and sweat gland decreases.

Answer 13

Skin becomes dryer. Pruritus(itching) May occur. Nursing strategies-Clean perineal area Daily but do not be the full body on a daily basis, Apply lotion as needed, Encourage adequate hydration.

Question 14

Age related skin integrity - cell renewal is shorter

Answer 14

Healing time is delayed.Nursing strategies-Perform careful skin assessment looking for signs of skin breakdown.

Question 15

Age related skin integrity- melanocytes (cells that make the pigment that colors hair and skin ) decline in number

Answer 15

Hair become gray white.Skin may be on evenly pigmented. Nursing strategies-Assist patient with skin check observing for any signs of melanoma or other skin abnormalities.

Question 16

Age related skin integrity-Collagen fiber is less organized

Answer 16

Skin lose this elasticity. Nursing strategy-Check skin frequently for tears irritation or breakdown

Question 17

Changes in health state - skin alternation

Answer 17

Dehydration or Malnutrition.Reduce sensation.Nursing implications-If fluid protein and vitamin C intake is deficient skin loses elasticity and become prone to break down.Nursing care is directed toward preventing skin breakdown frequent change of patient position with skin assessment at each change special mattress and protection of bony prominence use of lotion and attention to fluid in nutritional status. Patient inability to sense temperature extremes pressure friction and other factor can easily result in injury nursing care incorporate special attention to safety.

Question 18

Illness - skin alternation

Answer 18

Diabetes. Nursing implications- Numerous factors combined to cause skin problem in diabetic patient cuts and sore that do not heal lesion on the lower extremities that ulcerate and become Necrotic and re-current bacterial and fungal infection.The diabetic patient must be taught special hygiene measure to prevent trauma to the skin in learn to assess the skin carefully to detect any alternation.

Question 19

Diagnostic measures - Skin alternation

Answer 19

Gastrointestinal series. Nursing implications-The G.I. cleaning and preparation and minister to patient having G.I. studies done may result in diarrhea which irritate the sensitive skin in the peroneal area specially if the patient had a bout of diarrhea before the study anticipating the problem is notingRedness and inflammation and beginning warm bath and ointments You’re welcome nursing measure the patient may be too embarrassed to seek.

Question 20

Therapeutic measures-Skin alternation

Answer 20

Bed rest, Cast,Aqua thermia unit, medication, and radiation therapy. Nursing implication-Bed rest predispose Patient to skin breakdown the harsh detergent use on hospital laundry compound the problem.Pressure point needs to be examined frequently and protected.Cash easily irritate the skin care full assessment covering the rough edges of the cats and skin care are indicated.Where he has therapeutic benefit but if applied to the skin for too long May macerate The skin follow protocol in application Examine skin carefully between treatment and allow to dry.Medication may cause allergic skin reaction such as rash.When evaluating the patient response to a new drug exam in the skin for redness and itching. Radiation therapy expose normal skin cells as well as cancer cells in treatment feel to effect of radiation with the potential for erythema And moist desquamation( loss of skin integrity).

Question 21

Erythema

Answer 21

Redness of the skinCaused by the dilation of superficial blood vessel associated with sunburn inflammation and fever trauma or allergic reaction. People with darker skin tone it is important to assess skin temperature area of erythema Will feel warm compared to surrounding area.

Question 22

Cyanosis

Answer 22

Bluish or grayish discoloration of the skin in response to inadequate oxygenation.In darker skin patient they appear as dullness.

Question 23

Jaundice

Answer 23

A yellow color of the skin resulting from elevated amount of Bilirubin In the blood.Associated with liver and gallbladder disease or some type of anemia and excessive hemolysis ( breakdown of red blood cell). In darker skin patient the sclera oral mucous membranes palm and soles appears yellow

Question 24

Pallor

Answer 24

Paleness of the skin often result from a decrease in the amount of circulating blood ( shock ) or hemoglobin causing in adequate oxygenation of the body tissue. Dark skin patient is seen as in gray or yellow tinge.

Question 25

Vitiligo

Answer 25

White patch the area of the skin.Depigmentation( congenital or auto immune condition)

Question 26

Ecchymosis

Answer 26

A collection of blood in the subcutaneous tissue causing purpleish discoloration.

Question 27

Petechiae

Answer 27

Small hemorrhagic spot caused by capillary bleeding.If present access location color and size.

Question 28

Turgor

Answer 28

Full Ness or elasticity of the skin

Question 29

Edema ( excess fluid in the tissue )

Answer 29

Swelling, with taut and shiny skin over the edamatous area.

Question 30

Lesions

Answer 30

Area of disease or injured tissue such as bruises scratches and cuts and burns insect bites and wounds.

Question 31

Primary lesions

Answer 31

Those that may arise from previously normal skin. Macula(freckles),patch(vitiligo),papule(mole),plaque(coalesced papule),nodule(wart),tumor(lipoma),wheal(hive),vesicle(herpes simplex),bulla(2nd degree burn),pustule(acne).

Question 32

Secondary lesions

Answer 32

Result from changes in primary lesions. Erosion - Loss of superficial epidermis, moist, non bleeding surface ex. Moist area after rupture of a vesicle as in chickenpox. Ulcer - loss of epidermis and dermis May bleed and scar ex. Stasis ulcer. Fissure - deep linear crack, extend into dermis ex. Athlete foot. Crust - dried residue of serum, pus, or blood ex. Impetigo. Scale - thin flake of exfoliated dermis ex. Dandruff dry skin.

Question 33

Miscellaneous lesions

Answer 33

Lichenification - thickened and roughened epidermis with increased visibility of skin furrows ex. Atrophic dermatitis. Atrophy - thinning of the skin, loss of skin furrows, shiny appearance ex. Peripheral vascular disease. Excoriation - scratch of the epidermis. Scar - fibrous tissue replaces tissue in the dermis or subcutaneous layer. Keloid - hypertrophied scar. Comedo - plugged opening of a sebaceous gland a hallmark of acne ex. Blackhead. Telangiectasia - small dilated red Or bluish surface vessels maybe part of a basal cell carcinoma or skin injury from radiation. Nevus- flat To slightly elevated round evenly pigmented ex. Mole

Question 34

Onycholysis

Answer 34

Separation of the nail plate from the nail bed

Question 35

Beau lines

Answer 35

Indentation within nailbed From acute your illnesses

Question 36

Clubbing

Answer 36

From long-term lack of oxygenation

Question 37

Hirsutism

Answer 37

Excessive amount of hair on the face and body

Question 38

Normal age related Skin variation in newborns and children

Answer 38

Jaundice and milia in newborn. Fine downy Hair for the first two weeks of life. Smooth thin skin at birth. Pubic hair development at the onset of puberty.

Question 39

Older adults skin variation

Answer 39

Wrinkles dryness scaling decrease turgor. Raised black area ( senile keratosis). Flat brown age spot ( senile lentigines ). Small round red spot(cherry angioma). Find Brittle gray or white hair. Hair loss. Coarse Facial hair in women decrease body hair in men and women. Thick yellow toenails.

Question 40

Alopecia

Answer 40

Absence or loss of hair

Question 41

Pressure ulcer

Answer 41

A wound with a localized area of injury to the skin and underlying tissue.Develop went soft tissue is compressed between a Bony prominence And an External surface for a prolonged period of time Or when soft tissue undergo pressure in combination with sheer or friction.

Question 42

Risk factors for developing pressure ulcer

Answer 42

Pressure friction sheer immobility nutrition hydration skin moister mental status and age

Question 43

Stage one pressure ulcer

Answer 43

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching its color may differ from the surrounding area the area may be painful firm soft warmer or cooler as compared to adjacent tissue stage one may be difficult to detect an individual with dark skin tones.

Question 44

Stage two pressure ulcer

Answer 44

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed. Present as a shiny or dryShallow ulcer without bruising. It may also present as an intact or open rupture filled Blister.

Question 45

Stage three pressure ulcers

Answer 45

For thickness tissue loss. Subcutaneous That may be visible but bone tendon or muscleAre not exposed bone is not visible or directly palpable. Slough Maybe present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of stage III pressure Also varies by anatomic Location.The bridge of the nose ears, occiput and malleolus Do not have subcutaneous tissue, And stage III ulcer at these location can be shallow. In contrast area with significant adipose tissue can develop extremely deep stage III pressure ulcer.

Question 46

Stage four pressure ulcer

Answer 46

For thickness tissue loss with exposed bone tendon or muscle.Exposed bone is visible or directly palpable.Slough may be present on some part of the wound bed.Often includes undermining and tunneling.The death of a stage four pressure ulcer varies by anatomic location. Can extend into muscle or supporting structure making osteomyelitis possible.

Question 47

Unstageable pressure ulcer

Answer 47

For thickness tissue loss in which the base of the Ulcer is covered by sslough And eschar In the wound bed. Until enough slough and eschar Is removed to expose the base of the wound and therefore stage cannot be determined. Stable eschar On the heel serve as the body natural cover and should not be removed.

Question 48

Branden scaleFor predicting pressure sore rest

Answer 48

23-1 the higher the score the lower the risk

Question 49

Preventing pressure ulcer

Answer 49

Assess the skin of patient at risk on a daily basis. Pay particular attention to bony prominence.Cleanse the skin routinely and whenever any swelling occurs.Use a mile cleaning agent minimal friction and avoid hot water.Maintain higher humidity in the environment and you skin moisturizer for dry skin. A void massage over Bony prominence. Protect the skin from oMoisture associated with episode of incontinence or exposure to drainage.Minimize skin injury from friction and sheer force by using proper positioning turning and transferring technique.Use appropriate support surface.Investigate reason for in adequate dietary intake administer nutritional supplement or nutritional interventions.Continued effort to improve mobility and activity.Document measure used to prevent pressure ulcer and the result of these interventions

Question 50

Nursing diagnosis related to skin alteration

Answer 50

Impaired skin integrity - Any condition that alter the dermis or epidermis , risk for infection - Any condition that interferes with the normal inflammatory healing process or provide an entry for infectious agent, disturbed body image - Any condition that causes confusion in the mental state of oneself.

Question 51

Risk factors for pressure ulcer development

Answer 51

Immobility nutrition and hydration skin moisture mental status and age dehydration incontinence skin hygiene diabetes diminished pain awareness fracture history of corticosteroids therapy Immune suppression multi system trauma poor circulation previous pressure ulcer significant obesity or tthinness