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Chapter 19 Test 1 > Ch 19 Test 1 > Flashcards

Ch 19 Test 1 Flashcards

1
Q

Functions of the skin

A

Protection
Sensation
Temp regulation
Excretion and secretion

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2
Q

What changes occur in skin with aging

A
  1. Lost elastic fibers/adipose tissue sub q, causes to be thinner, wrinkle/sag
  2. loss collagen, more fragile slow heal
  3. Decreased sebaceous gland dry itchy skin
  4. Temp control altered. Cold intolerance
  5. Hair thins, grow slowly decrease number follicles,loses color- loss melanocytes
  6. Nail growth decreases nails thicken
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3
Q

What is reactive hyperemia?

A

Process by which blood rushes into a place where there was a decrease in cicruclation.

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4
Q

Within how many minutes should redness subside from skin before it is working its way to a stage 1 pressure ulcer?

A

45 minutes

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5
Q

Major contributing factors for pressure injury

A 
Immobility 
Inactivity
Moisture
Malnutrition
Advanced age
Altered sensory perception
Lowered mental awareness
Friction and shear
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6
Q

Minor contributing factors for pressure injury

A

Dehydration
obesity
Edema

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7
Q

When should you first do a skin exam?

A 
Upon admission( or at least within 8 hours)  perform a detailed skin exam noting appearance.use braden scale . Pay attention to skin over bony prominences.
Reassess every shift.
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8
Q

The braden scale for predicting pressure sore risk from 1 bei mb very poor to 4 being no impairment

A 
Asseses point based 9n
 sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
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9
Q

An area of skin is red, deep pink, mottled does not BLANCH with fingertip pressure. Darker skin may have a discolorationnof surrounding tissue. Warmth, edema, and induration ( area feels hard)

A

Stage 1 pressure injury

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10
Q

Partial thickness skin loss exposed dermis, wound is pink or red. Looks like a ruptured blister

A

Stage 2 pressure injury

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11
Q

Full thickness skin loss looks like CRATER. extends to fascia. SUBQ skin damaged NECROTIC. fat is visible.UNDERMINING / TUNNELING present. May be damage to surrounding tissue.

A

Stage 3 C.U.T

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12
Q

Full thickness skin loss,extensive NECROSIS DRY BLACK NECROTIC ESCHAR. wet and oozing

A

Stage 4 pressure injury

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13
Q

Loss full thickness . BASE OF INJURY COMPLETELY BLACK OR BROWN. COVERED BY ESCHAR

A

Unstageable.

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14
Q

Purple deep tissue, broken MAROON OR PURPLEblood filled damage to underlying soft tissue from pressure or shearing.

A

deep tissue pressure injury

AKA DEEP PURPLE

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15
Q

How often should ot be repositioned in a wheelchair or chair?

A

1 hour

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16
Q

How often shoukd ot be repisitioned in bed

A

Every 2 hours

17
Q

Should you massage redened ski

A

NO! it has already been damaged. Avoid massage over bony prominences.

18
Q

Why isnt a full bath needed wvery day?

A

Decreased sweat and sebaceous gland activity

Personal preference

19
Q

Thinner skin/decreased sub q fat, pts can have chilling. How can we prevent.

A

Pre warm bath

Give adequate draping.

20
Q

Type of bath that replaces tub ir shower and can be given in a bath shower or bed

A

Cleansing bath

21
Q

Type bath that healing or medicinal. Whirlpool, oatmeal

A

Therapeutic

22
Q

Type moist heat clean anal perineal area. Needs order

A

Sitz bath

23
Q

Type bath that cleanses ooen wounds aplied medicine solutionsfeet arms soaked

A

Body soak

24
Q

Tyoe bathneeds order to bring down fever

A

Sponge bath

25
Q

Do older pts need a full bath every day?

A

No, pre warm the water, draoe pt, mild soao pat dry, prevent slios falks

26
Q

Benefits of back massage

A 
Communicates caring
Fosters trust
Opportunity to assess skin
Stimulates circulation to area
Reduces tension promotes relaxation
27
Q

Perineal care

A

Ensure proper draping

28
Q

Mouth care times unconscious

A

At least ince every 4 hours with moist swabbing every 2 hours
Check gag reflex
Make sure dont aspirate communicatemcan turn to side

29
Q

Mouth care times concius

A

Raise bed 45-90 every 4 hours

30
Q

Shaving

A

No shave before surgery

May not shave beard or mustache withiut order

31
Q

Nail care

A

Straight across cuts
Ve aware of diabetic circukation issues
So dont cut on diabetic pts withiut order

32
Q

Ear care

A

Not with q tios can push wax in

Be careful w hearing aids

Chapter 19 Test 1 (1 decks)

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