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Med Surg II Nrsg 110 > Exam #2 > Flashcards

Exam #2 Flashcards

1
Q

How are skin lesions primarily assessed?

A

Color.

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2
Q

How else are they assessed?

A

Irregular border, shape, diameter > 5-6mm.

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3
Q

What signs do you look for when inspecting the skin?

A

Edema, moisture, petechiae, ecchymoses.

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4
Q

What signs do you look for when inspecting the skin in a darker skinned patient?

A

Pallor (ask grey of mucous membranes), Cyanosis (lips, tongue, nail beds, palms, soles), Inflammation (warmth and redness), Jaundice (hard palate), Skin bleed (darker).

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5
Q

Where do you look for skin tears, especially on the elderly patients?

A

Where their clothing rubs, upper extremities where the skin is grasped, under tapes and dressings.

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6
Q

What is the difference between a macular rash and a papular rash?

A

Macular rashes are flat and papular rashes are raised.

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7
Q

Where is it best to assess skin temperature?

A

On the forearm with the back of you hand.

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8
Q

Describe the differences between 1st, 2nd, and 3rd intention healing.

A

1st = clean cut, sewed shut, thin scar. 2nd = deep, wide, granulated, not swen. 3rd = delayed closure, granulation, risk for infection, scar.

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9
Q

When skin and underlying tissue are pressed against a bony prominence or external surface for a period of time it can cause a _____, or tissue _____.

A

Pressure ulcer. Anoxia.

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10
Q

Name all 9 risk factors for pressure ulcers.

A

Impaired mental status, sensory deficits, immobility, elderly, very thin or obese, mechanical, shearing or friction, moisture or secretions, impaired nutritional status.

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11
Q

What is the best way to prevent pressure ulcers?

A

Shift your weight (even the slightess mvmt) q15mins.

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12
Q

Should you massage reddened areas or the legs of those at risk for DVT?

A

No!

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13
Q

In the clinical setting, how often should you turn a patient?

A

Every 2 hours minimum.

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14
Q

What are the scoring ranges on the Braden scale?

A

11 or under = severe, 12-14 = moderate, 15-16 = mild.

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15
Q

What does black, yellow, and red tissue indicate?

A

Black = necrosis, yellow = infection, red = healing.

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16
Q

What are the 4 stages of pressure ulcers? Describe them.

A

Stage 1 = red, unblanchable, skin intact. Stage 2 = Partial thickness skin loss. Stage 3 = Full thickness skin loss, may have some eschar. Stage 4 = Damage to muscle, bone, and/or support.

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17
Q

Which method of debridement is NON-selective?

A

Mechanical.

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18
Q

Which type of debridement is selective? What are its advantages and disadvantages?

A

Some enzymatic debriders are selective, but not all. Advantages - it is fast acting with minimal damage to healthy tissue. Disadvantages - expensive, need prescription, must be carefully applied, may have discomfort.

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19
Q

How does the autolytic method of debridement work and when is it used?

A

It uses the body’s own enzymes. Best used in stage 3 or 4 with light to moderate exudate.

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20
Q

What method of debridement is fastest?

A

Surgical

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21
Q

What does negative pressure wound therapy provide and what DON’T you use on it?

A

It provides drainage and vascularization, and you should NEVER put it over healthy tissue. Usually used on ST3 or ST4.

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22
Q

What changes to an ulcer should you inform the provider of?

A

Sudden deterioration or increase in size or depth. Changes in color or texture of granulated tissue.

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23
Q

What albumin level is considered a sign of impaired nutritional status? Lymphocytes?

A

Albumin < 3.5mg/dL. Lymphocytes < 1800mm3.

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24
Q

What % weight loss is considered INS?

A

Greater than 15% of body weight.

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25
Q

What is cellulitis?

A

Inflammation or infection of the skin, connective tissue by staph or strep.

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26
Q

What causes cellulitis?

A

Open wound or trauma or may be unknown.

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27
Q

What are s/s of cellulitis and what can it mimic?

A

Warmth, redness, edema, pain, tender, fever, lymphadenopathy. Can mimic DVT, but no fever in DVT.

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28
Q

What is Lymphadenopathy?

A

Swollen lymph gland.

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29
Q

How is cellulitis diagnosed?

A

Tissue and/or blood cultures.

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30
Q

What can be done about cellulitis?

A

Antibiotics and/or debridement.

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31
Q

Describe the difference between Herpes 1 and 2.

A

Same virus. 1 above the waist and 2 is below the waist.

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32
Q

What is autoinoculation?

A

The transfer of a pathogen from one part of the body to another.

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33
Q

What usually brings on a recurrence of herpes 1?

A

Stress

34
Q

What are the stages of a herpes 1 breakout?

A

Prodromal - burning, tingling then vesicles, pustules. Contagious until scabbed.

35
Q

What drug is used for herpes 1?

A

Acyclovir (Zovirax).

36
Q

What is shingles?

A

Herpes Zoster. A disease caused by reactivation of the chicken pox virus.

37
Q

What causes it to activate?

A

Occurs with reduced immune function. More common in the elderly, AIDs patients.

38
Q

What are the s/s of Herpes Zoster?

A

Vesicles and/or plaques along a nerve, itching, fever, malaise, pain.

39
Q

What is defined as burning, pain along a nerve?

A

Postherpetic neuralgia.

40
Q

What is defined as burning, pain at a nerve ending?

A

Persistant dermatomal pain. A dermatome is an area of skin that is mainly supplied by a single spinal nerve.

41
Q

Define Hyperesthesia.

A

Hypersensitivity.

42
Q

What nerve does opthalmic herpes zoster affect?

A

Opthalmic branch of the trigeminal nerve.

43
Q

What can be done about a case of shingles? What are the steroids for? Antihistamines?

A

Acyclovir, antibiotics for secondary infections, analgesics, steroids, antihistamines. Pain. Burning and itching.

44
Q

What is dermatophytosis?

A

Fungal skin infections.

45
Q

What type of environment do fungi need?

A

Warm and moist.

46
Q

Name and describe the 4 types of fungal infections?

A

Tinea pedis (athlete’s foot), tinea capitas (head), tinea corporis (body), tinea cruris (groin).

47
Q

What are some interventions for fungal infection?

A

Keep it clean and dry, topical and/or oral antifungals, steroids, teaching.

48
Q

Name 2 common inflammatory conditions of the skin.

A

Dermatitis and psoriasis.

49
Q

What is dermatitis of the skin and what causes it?

A

Inflammation. Allergens, irritants, heredity, stress.

50
Q

What type of dermatitis is eczema?

A

Atopic dermatitis.

51
Q

Name some s/s of eczema.

A

Crusts, fissures, lesions, macules, pustules, papules.

52
Q

What are its complications?

A

Infection, sepsis.

53
Q

What are some interventions?

A

Antihistamines, analgesics, antipruritics, colloidal oatmeal baths, steroids, wet dressings.

54
Q

What is psoriasis?

A

An inflammatory disorder of the skin with a proliferation of epithelial cells and scaling.

55
Q

How long does psoriasis last?

A

Lifelong with exacerbations and remissions.

56
Q

What are some causes of psoriasis?

A

Cold weather, hormones, skin trauma, drugs, stress, strep pharygitis.

57
Q

What are some s/s of psoriasis?

A

Papules, plaques, scales, itching, yellow fingernails.

58
Q

What are some complications of psoriasis?

A

Infection, fever, chills, lymphadenopathy, yellowing of the nails.

59
Q

What are some therapeutic interventions for psoriasis?

A

Tub baths, steroids, aspirin, keratolytics, coal tar, UV light, chemotherapy, occlusive dressings.

60
Q

What are venous stasis ulcers?

A

Ulcers caused by venous stasis. Lack of venous blood flow in the legs causes tissue death, often at the ankle, or in some cases at the kankle.

61
Q

What are some s/s of venous stasis?

A

Edema, brownish hardened skin.

62
Q

What is the #1 way to diagnose Psoriasis?

A

Physical assessment.

63
Q

Name some therapeutic interventions for venous stasis?

A

Decrease edema and/or heal ulcerations, compression wraps and/or unna boot, skin grafts, walk, avoid standing, bedrest with the legs elevated.

64
Q

What are some nursing interventions for venous stasis?

A

Elevate and protect legs, do not cross your legs, avoid heat, compression from foot upward.

65
Q

Where should eschar not be removed from?

A

The heels.

66
Q

What is the difference between a strain and a sprain?

A

Sprains involve ligaments. Strains just involve muscle and tendons.

67
Q

What is a strain?

A

Excessive stretching of a muscle or tendon when it is weak or unstable.

68
Q

What do you do for a strain?

A

Cold and heat, limit activity, high dose NSAIDs (600-800mg), muscle relaxant, possible surgery.

69
Q

How many degrees of sprains are there?

A

3.

70
Q

Define a 1st degree sprain.

A

Only a few ligament fibers are damaged.

71
Q

Define a 2nd degree sprain.

A

Refers to a more extensive damage to the ligament with associated swelling.

72
Q

Define a 3rd degree sprain.

A

Refers to a complete rupture of the ligament with swelling and a possible joint dislocation.

73
Q

What is done for a first-degree sprain?

A

Rest, ice for 24 to 48 hr, compression bandage, and elevation.

74
Q

What is done for a second-degree sprain?

A

Immobilization, partial weight bearing as tear heals.

75
Q

What is done for a third-degree sprain?

A

Immobilization for 4 to 6 weeks, possible surgery.

76
Q

What is Carpal Tunnel Syndrome?

A

Common condition in which the median nerve in the wrist becomes compressed causing pain & numbness

77
Q

What causes Carpal Tunnel Syndrome?

A

Common repetitive strain injury via occupational or sports motions. Occurs with swelling in tunnel.

78
Q

Where does the pain/numbness occur in carpal tunnel?

A

Fingers, hand, arm

79
Q

What can be done for carpal tunnel?

A

Rest it, splint it, relieve it (anti-inflammatory meds), surgery

80
Q

What finger (or fingers) is not innervated by the median nerve?

A

The pinkie finger.

81
Q

What does R.I.C.E. stand for and what is it Nursing care for?

A

Rest, Ice, Compression, & Elevation. Nursing care for sprains and strains.

Med Surg II Nrsg 110 (8 decks)

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