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Nursing Semester 3 > Cyndi - Week 14 - Exam 7 > Flashcards

Cyndi - Week 14 - Exam 7 Flashcards

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1
Q

what is important to do for skin protection?

A

Use sunscreen, lip balm, protective clothing from birth to death for skin
protection

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2
Q

where should you assess a dark person’s skin? what is a characteristic of those with light skin?

A

In darker skin people, assess oral membranes, conjunctiva, palms and soles
***those with light skin are more likely to have skin problems

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3
Q

how do medications affect skin?

A

Medications can potentiate sun sensitivity and skin changes

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4
Q

what are the characteristics of an older person’s skin?

A

Older persons have dry skin, with increased fragility
• Sagging
• Slower to show turgor
• Easier to bruise or tear

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5
Q

what are the risk factors for skin cancer?

A
  • Fair skin
  • Sun exposure
  • Radiation exposure
  • Family history
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6
Q

what are the three types of skin cancer?

A
  • basal cell carcinoma
  • squamous cell carcinoma
  • malignant melanoma
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7
Q

what are the characteristics of basal cell carcinoma?

A
  • small, waxy
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8
Q

what are the characteristics of squamous cell carcinoma?

A
  • rough, thick
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9
Q

what are the characteristics of malignant melanoma?

A
  • tumor arising in melanocytes

- ABCDE

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10
Q

what does ABCDE stand for?

A
  • asymmetry
  • border (uneven)
  • color (multiple)
  • diameter ( >1/4 inch)
  • evolving (change in size, shape, and color)
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11
Q

what is malignant melanoma?

A

neoplastic growth of melanocytes

  • radical growth
  • vertical growth
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12
Q

where does malignant melanoma metastasize to?

A
  • lymph, heart, brain, lung, liver, or organ
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13
Q

what are the characteristics of malignant melanoma?

A
  • existing nevi/mole - larger > 5 mm diameter, “blue nevi”
  • often dark brown or black
  • most lethal of skin cancer
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14
Q

what are the locations of melanoma occurrences?

A
  • skin (90%)
  • eyes
  • remote internal site
  • unknown
  • mucous membranes
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15
Q

what are the diagnostic tests and treatments for skin cancer?

A
  • skin biopsies
  • lymph biopsy - remove enlarged lymph node
  • lactate dehydroogenase (LDH) - inc with malignancy
  • CT or MRI to r/o mets
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16
Q

what are the different types of skin biopsies?

A
  • Shave biopsy-shaves off the top layers
  • Punch biopsy-tiny round cookie cutter deep sample
  • Incisional biopsy – removes full thickness
  • Excisional biopsy -removes entire tumor
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17
Q

what are the post procedure education for diagnostic tests/tx?

A
  • Surgical excision
  • Signs and symptoms of infection
  • Pain management
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18
Q

what are the mechanism of injury for burns?

A 
•Thermal (heat)
   - Smoke Inhalation
   - Cold (Frostbite)
•Chemical
•Electricity
•Radiation
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19
Q

what is the severity determination of burns?

A 
• Burn Depth
- Superficial to full-thickness skin depth
• Extent - percent of total body surface
area burned (TBSA)
• Location of burn
• Risk of inhalation compromise
• Patient factors
20
Q

what are the three types of burn depth?

A
  • superficial, deep, full-thickness
21
Q

what is a superficial thickness burn? 1st degree burn

A
  • Epidermis and small portion of dermis involved
  • Red, swollen, painful, possible blisters
  • Capillary refill, hair follicles mostly intact
22
Q

what is a deep partial thickness (2nd degree)?

A
  • Injury extends to deeper dermal area

* Blisters, severe pain, mild to moderate edema

23
Q

what is a full thickness (3rd/4th degree)?

A
  • 3rd - fat, muscle & tendon
  • 4th - bone & nerves
  • Necrotic tissue forms – healing dry, waxy, leathery
  • Loss of sensation
24
Q

what is total body surface area (TBSA)?

A

Total body surface area (TBSA) of burn used
to calculate patient’s fluid needs and extent of
injury

25
Q

what are the characteristics of TBSA calculation?

A

•TBSA calculation - takes age into account
• Rule of nines chart
• Lund-Browder chart
• Superficial partial-thickness not represented
• Tracks only deep partial-thickness and full thickness
injury

26
Q

It’s important to suspect smoke inhalation injury wherever there is: ???

A
  • Indoor smoke or fire exposure, or entrapment
  • Carbon stain or singed hair on face or neck
  • Hoarse voice or dark sputum
  • Carbon monoxide poisoning
  • Clues for suspicion of injury
  • Damage to the respiratory tract from heat or chemicals
  • Injury above glottis
  • Injury below glottis
27
Q

T/F: Control airway proactively as swelling may prevent intubation later

A

TRUE

28
Q

what is the basic lab tests for burns?

A
  • CBC
  • Lytes
  • CPK
  • UA
  • ABG
  • Carboxyhemoglobin level if indicated
29
Q

what are the different location of burns?

A

Hands, feet, face, eyes, ears, joints or perineum, circumferential burns

30
Q

what are the localized zones of injury?

A
  • Zone of coagulation
  • Zone of stasis
  • Zone of hyperemia
31
Q

what are the systemic response of burns?

A
  • Stress response
  • Fluid loss
  • Hypermetabolic state
  • Systemic effects of burns – pulmonary, GI, kidney, immunity systems`
32
Q

what is the Parkfield Formula?

A

volume of LR = 4 mL x % BSA x weight (kg)

**1/2 first 8 hrs then 1/2 next 16 hours

33
Q

what are the phases of burn management?

A
  • emergent phase
  • acute phase
  • rehabilitation phase
34
Q

what is the emergent phase?

A
  • until immediate life threatening issues
    resolved - up to 72 hours
    •Prehospital phase – rescue and transport
    •Hospital – emergent care – may be transferred to burn center
35
Q

what is the acute phase?

A
  • from mobilization of extracellular fluid to wound

stability

36
Q

what is rehabilitation phase?

A

recovery

37
Q

what are the characteristics of the emergent phase?

A

Onset of injury until fluid resuscitation complete
• ↑ capillary permeability = intravascular volume depletion
•Insensible fluid loss – skin and respiratory
•Electrolyte shifts
• Na+ out of blood - into interstitium and cell
• K+ out of cell - into interstitium and blood
•Inflammation response
•Immune dysfunction
•Chemical burn – flush area with water for 20 min
•Electrical burn – may have other trauma
•Radiation – contain contamination

38
Q

what does the patient look like in the emergent phase?

A 
•Shock From Pain And Hypovolemia
•There may be other injuries and trauma as well
•Blisters
•Bowel Ileus
•Shivering
•Frightened
•Altered Mental Status
***opioid analgesic before any intervention
39
Q

what is the treatment of the emergent phase?

A
  • Airway management – watch closely and intubate early
  • Fluid resuscitation – Parkland Formula – accurate hourly I&O (F catheter)
  • Wound care - decrease infection risk
  • Dressing changes, premedicate with pain meds, debridement as needed
  • ROM to preserve function of joints
  • Medications
  • Nutrition
40
Q

what are the meds given in the emergent phase?

A
  • Treat pain with analgesics (IV, PCA)
  • Administer tetanus booster if indicated
  • Give antimicrobials
  • Administer DVT and ulcer prophylaxis
41
Q

what are the characteristics of the acute phase?

A

Begins when extracellular fluid begins to shift back to
normal compartments (48-72 hrs) until wound healed
•Diuresis of extra fluid – continued strict I&O
•Patient more aware, has anxiety, needs emotional support
**Most common cause of death after 72 hours is infection

42
Q

what is the tx for acute phase?

A
  • Nutritional needs - increased protein, calories, and vitamins
  • Bowel sounds return - enteral feeding will keep GI tract healthy
  • Dressing changes - strict surgical aseptic technique
  • Pain control plan
  • Usually not ATBs unless infection or surgery
43
Q

what are the characteristics of burn wound care?

A
  • early and continuous
    • Dressing changes –
    • Topical antimicrobial agents
    • Silvadene, Acticoat antimicrobial barrier dressing
44
Q

what kinds of surgeries can burn victims get?

A
  • Escharotomy – fasciotomy
  • Grafting – donor and graft sites
  • Debridement
  • Hydrotherapy
  • The skin gun
45
Q

how can you prevent complications?

A 
Prevent complications!
Assess for erythema, odor, and green or yellow exudate
•Electrolyte imbalances
•Infection
•Cardiovascular
•Respiratory
•Neurologic
•Musculoskeletal
•Gastrointestinal
•Endocrine
46
Q

what are the characteristics of the rehabilitation phase?

A

Begins when acute care needs are met
• Goal to return the patient to productive life
• Mobility limitations: positioning, skin care, exercise, ADLs, ambulatio

47
Q

what is the patient education for the rehabilitation phase?

A
  • Wound care and dressings
  • Signs and symptoms of complications
  • Exercises
  • Clothing and ADLs
  • Social skills

Nursing Semester 3 (29 decks)

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