307 Exam 1 (Modules 1-3) Flashcards by Erica Terry

What are the techniques used for a skin assessment?

Inspection and Palpation

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What do we Inspect the skin for?

Color, Texture, Integrity

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What do we palpate the skin for?

Moisture/Temp, texture, mobility and turgor.

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What 3 sources do humans obtain Vitamin D?

Sunlight, Food and Dietary supplements

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What 5 functions do the skin have?

Protect inner body parts and organs
Body Temp regulation
Sensor perception of temp, touch and pain
Excrete wastes and toxic substances
Produce Vitamin D

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What are three examples of hyperpigmentation?

Birth Marks
Sun Damage
Pregnancy changes

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3 examples of hypopigmentation?

Scars, stretch marks and vitiligo

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What is Vitiligo?

The lack or absence of the brown melanin pigment

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Cyanosis

Blue or Purplish discoloration of the skin (Easiest to see at fingers, lips, toes)

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Ecchymosis

Bruising (Bleeding under the skin)
Larger than Petechiae.
Greater than 3mm

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Erythema

Redness of the skin caused by the dilation of the superficial capillaries.

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Jaundice

Yellow discoloration of the skin and mucous membranes sclerae due to abnormal amounts of bilirubin in the blood.

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Pallor

A paleness or decrease of absence of skin coloration.

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Petechiae

Small round purplish red spots.
Caused by hemorrhage into the skin.
1-3mm

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Atrophic Scars

Have a depression in them from lost of epidermis

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Striae and Stretch marks are what type of scars?

Atrophic Scars

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Keloid Scars

Extends over the border of original wound and is smooth and rubbery

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How long does is take keloid scars to appear after the original injury?

Anywhere from Months-Years

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Extremely smooth and velvety skin could indicate what?

Thyroid disease

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What is Diaphoresis?

Excessive Precipitation

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How should you describe any skin lesions?

Color
Height
Shape
Location
Presence of drainage

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Purpura

Collection of petechiae and ecchymosis covering an area.

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What are Vascular lesions?

trauma, infection, or disease that allow leakage of capillaries into the dermis

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Petechiae/ Purpura and Ecchymosis are what type of lesions?

Vascular

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What lesions have a specific triggering agent which cause a change in previously intact skin?

Primary

Freckles, Mole, Measles, Scarlet Fever

Macule (FLAT) Less than 1CM area of pigment change.

Birthmark, Vitiligo and hormone changes?

Patch (FLAT) Larger than 1CM area of pigment change

Wart, Elevated Mole, Skin Tag

Papule (RAISED) Less than 1CM area

Psoriasis, Eczema

Plaque (RAISED) Larger than 1CM and in a disc shape.

Insect bites, Allergic Reaction and Hives (TB test is also one)

Wheal (RAISED, SOLID) Irregular area of edema on skin

Melanoma, hemangioma

Nodule (RAISED, SOLID) Less than 2CM firm area rising from deeper in the dermis

Lipoma and Neoplasm

Tumor (RAISED, SOLID) Larger than 2CM firm area rising from deeper in the dermis

Varicella chicken pox, shingles (Usually follows a nerve pathway) acute eczema

Vesicle (RAISED AND FLUID FILLED) less than 1CM and filled with serous fluid

Blister, Medication reaction

Bulla (RAISED AND FLUID FILLED) greater than 1CM and filled with serous fluid.

Acne, Herpes Simplex

Pustule (RAISED AND FLUID FILLED) less than 1CM and filled with purulent fluid.

Cyst acne or Sebaceous Cyst

Cyst (RAISED AND FLUID FILLED) arising from dermis filled with liquid or semisolid fluid.

These lesions evolve over time with changing characteristics

Secondary lesions

Chronic skin inflammation and Psoriasis

Lichenification, caused by long term and intense rubbing or scratching.

Scab and Eczema

CRUST, caused by intense rubbing or scratching.

Psoriasis or Eczema

SCALE, excessive shedding of keratin cells from the epidermis.

Cracks in the corner of the mouth or extremely dry hands and feet

FISSURE, straight line crack with abrupt edges going into the dermis.

Varicella, herpes simplex

EROSION, shallow depression appears moist but without bleeding.

Pressure Injury or poor blood flow to extremities

ULCERATIONS, may bleed.

Abrasions or scratching

Excoriation loss of epidermis in linear crusted areas.

True or False Patients with a lighter skin tone and exposure to UV rays have higher chance of developing skin cancer?

True

What is the ABCDE rule for assessing malignant skin lesions?

A asymmetry B border C color D diameter E evolving

-Red Area does not blanch with pressure -Texture different than surrounding areas - Temp warmer or cooler than surrounding areas

Stage 1 pressure Ulcer

-Partial loss of Dermis - Shiny or dry ulcer with pink wound bed -May present as ruptured blister or intact

Stage 2 Pressure Ulcer

-Full Tissue loss with damage or necrosis to the subcutaneous tissue -Subcutaneous fat may be visible - Dead tissue may be present in the wound bed.

Stage 3 Pressure Ulcer

-Full thickness and skin loss resulting in showing bones, tendons or muscles. -Dead tissue may be present in the wound bed.

Stage 4 Pressure Ulcer

Hyperthermia or hypothermia? -Shaking -Blurred Speech -Sleepiness Stiff Muscles -Confusion

Hypothermia

Hyperthermia or hypothermia? -Swelling in ankles or feet -Nausea/Weakness -Muscle cramps -Rapid pulse

Hyperthermia

Xerosis

Dry Skin

Nevus

Mole

Hives, skin rash with red raised and itchy bumps

Urticaria

Intense itching causing the desire to scratch

Pruritus

What are the 5 stages of the nursing process?

Assessment Analysis Planning Implementation Evaluation

Avoiding harm to others is an example of what ethical principal?

Nonmaleficence

Protecting the privacy of others is what ethical principal?

Confidentiality

Helping others in a positive manner is an example of what ethical principal?

Beneficence

Being open and fair describes what ethical principal?

Justice

Having control over your body and what happens to it is an example of what ethical principal?

Autonomy

True or false Therapeutic communication can be both verbal and non verbal?

True

ISBARR

Identify Situation Background Assessment Recommendation Recite

What does HIPPA stand for?

Health Insurance Portability and accountability act

Keeping a promise to a client is known as what ethical principal of nursing?

Fidelity

RR > 10-12/min

Bradypnea

HR >50/min

Bradycardia

HR< 100/min

Tachycardia

Shallow rapid breathing <20/min

Tachypnea

Give verbal instruction for how to take a orthostatic BP in 5 steps.

1 Place pt in supine position and allow to rest. 2 Take BP 3 Keep cuff in place and assist to seated 4 Take BP while stated 5 Assist to stand and get BP

True or False 120/80 is normal findings for an adult blood pressure

True

-Pt reports fever, malaise, chills, pain Multiple or single lesions (pustules, papule, nodular) -Lesions can be erythematous, edematous, painful, and warm to touch.

Cellulitis

give examples of nursing actions when a patient has sensory disability

-Keep call light accessible orient clients to the room -keep furniture clear from path to the bathroom -Keep client's personal items within reach -Bed lowest position -poles bags and tubes easy to move around.

Examples of nursing actions for hearing loss

-Sit and face clients -Speak slowly and clearly -Write down what client's don't understand

Examples of nursing actions for patients with vision loss

-Identify yourself -Stay within visual field if only partial loss -Make digital audio or radio available -Describe an arrangement of food on a tray before leaving.

Nursing actions for patients with aphasia

-Do not shout -Check for comprehension -Make sure only one person speaks at a time.

Nursing actions for patients who are disoriented

Maintain Eye contact at eye level Ask only one question at a time Give directions one step at a time.

For the GENERAL SURVEY what should we notice about the patient

Appearance Behavior Body Structure Mobility

What objective information do we obtain from a patient during the GENERAL SURVEY

Height Weight BMI Vital Signs Pain Scale Assessment

When assessing behavior what 3 things should you take notice of?

Speech, Mood and Affect.

During the general survey what unexpected findings should the nurse look for in a patients awareness?

Confusion (Awake) Lethargy (Not fully awake) Stupor (Unconscious but responds to stimuli physical or verbal ) Obtundation (Is asleep, only arouses with loud audio or physical interaction) Comatose (Unconscious and no stimuli reaction)

Obtundation

A reduction in awareness in which environmental stimuli fail to illicit a reaction from patient.

What is Echolalia

Meaningless repetition of words.

What is Dysarthria?

Difficult or unclear articulation of speech.

What is Crepitus

Cracking sound when bone rubs together.